Autogenic Training

Micah R.
Sadigh, PhD
Autogenic Training
A Mind-Body Approach
to the Treatment of Fibromyalgia
and Chronic Pain Syndrome
ing and highlights its benefits, Dr.

Pre-publication Sadigh speaks to the advantages of
REVIEWS, a multidisciplinary approach in the
COMMENTARIES, treatment of pain and other disorders
EVALUATIONS . . . related to chronic stress. He specifi-
cally evaluates interventions that range
from pharmacological ones to a num-
“D r. Sadigh’s book is a scholarly
but highly readable treatise
that expertly covers therapeutic tech-
ber of other nonpharmacological stress-
reduction techniques. This ‘global’ pic-
ture permits the reader or practitioner
niques for improving chronic pain to appreciate autogenic training within
and relieving stress. He also authori- the context of other treatments for
tatively tackles the problem of sleep chronic pain, fibromyalgia, fatigue,
disorders. His book is all the more im- and a host of other disorders.
portant today because these debilitat- Dr. Sadigh’s book is a must-read
ing conditions seem to be on the infor any professional who occasionally
crease. Dr. Sadigh convincingly con- or regularly treats people with chronic
tends that the experiences of stress pain, fibromyalgia, sleep problems, or
and chronic pain are synergistically any other disorder in which stress can
intertwined. Thus, the reduction of be a significant contributor.”
stress is a preponderant part of the
protocol of any treatment aimed at Constance P. Dent, PhD
pain management. Director,
Even though the book details the Countryside Haven for Health,
specific procedures of autogenic train- Mertztown, PA
More pre-publication
REVIEWS, COMMENTARIES, EVALUATIONS . . .
“D r. Sadigh provides clinicians

with a clear, focused, detailed
approach to clinically manage chronic
clinical techniques should give this
book a very long shelf life. Supervi-
sors and students alike will find it a
pain syndromes that represents the valuable addition to their arsenal of
best scientific and therapeutic knowl- clinical resources. The lucid reformu-
edge we have to date. In this schol- lation of hitherto fragmented, ob-
arly, yet immensely practical book, scure, and disparate literatures on
the reader has access to everything autogenic training, clinical biofeed-
needed to effectively treat fibro-
back, and pain and stress manage-
myalgia and other chronic pain syn-
dromes. A worthy effort. Extremely ment techniques provides a timely,
well done!” compact, and authoritative treatise.
The question and answer section
along with various exercise formats
David F. O’Connell, PhD
Attending Psychologist, and patient checklists are bonuses not
Executive/Professionals Health ordinarily found in such publications.
and Recovery Program, The wealth of information, case stud-
The Caron Foundation ies, and step-by-step applications of-
fered on these pages will be of consid-
erable interest to every professional in
health care and rehabilitation.”
Kenneth Anchor, PhD

“T his long overdue and emi-
nently readable volume is a
milestone for behaviorally oriented
Administrative Officer,
The American Board of Medical
Psychotherapists and Psychodiagnosticians;
practitioners. Dr. Sadigh’s emphasis Director, Center for Disability Studies,
on practical applications of powerful Nashville, TN
The Haworth Medical Press®

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Autogenic Training
®
THE HAWORTH MEDICAL PRESS
Chronic Fatigue Syndrome, Fibromyalgia Syndrome,
and Myalgic Encephalomyelitis
Roberto Patarca-Montero, MD, PhD

Senior Editor
Concise Encyclopedia of Chronic Fatigue Syndrome by Roberto

Patarca-Montero
CFIDS, Fibromyalgia, and the Virus-Allergy Link: Hidden Viruses,

Allergies, and Uncommon Fatigue/Pain Disorders by R. Bruce
Duncan
Adolescence and Myalgic Encephalomyelitis/Chronic Fatigue

Syndrome: Journeys with the Dragon by Naida Edgar
Brotherston
Phytotherapy of Chronic Fatigue Syndrome: Evidence-Based

and Potentially Useful Botanicals in the Treatment of CFS
by Roberto Patarca-Montero
Autogenic Training: A Mind-Body Approach to the Treatment

of Fibromyalgia and Chronic Pain Syndrome by Micah R.
Sadigh
Enteroviral and Toxin Mediated Myalgic Encephalomyelitis/

Chronic Fatigue Syndrome and Other Organ Pathologies
by John Richardson
Treatment of Chronic Fatigue Syndrome in the Antiviral Revolution

Era by Roberto Patarca-Montero
Autogenic Training
Micah R. Sadigh, PhD
The Haworth Medical Press®

An Imprint of The Haworth Press, Inc.
New York • London • Oxford
Published by
The Haworth Medical Press ®, an imprint of The Haworth Press, Inc., 10 Alice Street, Binghamton,
NY 13904-1580
© 2001 by The Haworth Press, Inc. All rights reserved. No part of this work may be reproduced or
utilized in any form or by any means, electronic or mechanical, including photocopying, microfilm,
and recording, or by any information storage and retrieval system, without permission in writing
from the publisher. Printed in the United States of America.
Medicine is an ever-changing science. As new research and clinical experience broaden our knowl-
edge, changes in treatment and drug therapy are required. While many suggestions for drug usages
are made herein, the book is intended for educational purposes only, and the author, editor, and pub-
lisher do not accept liability in the event of negative consequences incurred as a result of informa-
tion presented in this book. We do not claim that this information is necessarily accurate by the
rigid, scientific standard applied for medical proof, and therefore make no warranty, expressed or
implied, with respect to the material herein contained. Therefore the patient is urged to check the
product information sheet included in the package of each drug he or she plans to administer to be
certain the protocol followed is not in conflict with the manufacturer’s inserts. When a discrepancy
arises between these inserts and information in this book, the physician is encouraged to use his or
her best professional judgment.
This book is not intended as a substitute for appropriate diagnosis and treatment of medical condi-
tions. The information provided here needs to be used under close medical and psychological su-
pervision. The instructions in Chapter 5 on medical and psychological screening need to be
followed closely in order to avoid any undesirable effects. This is not a self-help book.
This book contains actual case presentations of patients who were effectively treated with
autogenic training. For the purpose of confidentiality, their names and certain demographic infor-
mation have been modified.
Cover design by Marylouise E. Doyle.
Library of Congress Cataloging-in-Publication Data
Sadigh, Micah R.
Autogenic training : a mind-body approach to the treatment of fibromyalgia and chronic pain
syndrome / Micah R. Sadigh.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7890-1255-3 (hard : alk. paper) — ISBN 0-7890-1256-1 (pbk. : alk. paper)
1. Chronic pain—Treatment. 2. Fibromyalgia—Treatment. 3. Autogenic training. I. Title:
Mind-body approach to the treatment of fibromyalgia and chronic pain syndrome. II. Title.
[DNLM: 1. Autogenic training—methods. 2. Chronic Disease. 3. Fibromyalgia—therapy.
4. Pain—therapy. WM 415 S125a 2001]
RB127 .S22 2001
616'.0472—dc21
00-050587
For El Elyon
ABOUT THE AUTHOR
Micah R. Sadigh, PhD, is a respected psychologist and research sci-

entist. A graduate of Moravian College and Lehigh University, he is
the author of many scientific papers and has contributed chapters to
various textbooks in psychology and behavioral medicine. He is an
acclaimed lecturer and is frequently invited to make presentations at
national and international conferences. At the present time, Dr. Sadigh
is lecturing extensively on his new integrated model of rehabilitation
medicine, which specifically focuses on the evaluation and treatment
of chronic pain.
For over ten years, Dr. Sadigh was Director of the Department of Psy-
chology and Behavioral Medicine at the Gateway Institute, a center
dedicated to the study and treatment of chronic pain. Currently, he
practices at Good Shepherd Hospital and is Faculty in Psychology
and Integrated Medicine at Cedar Crest College. He is a Fellow of the
International College of Psychosomatic Medicine; a Fellow and
Diplomate of the American Board of Medical Psychotherapists and
Psychodiagnosticians; a Fellow of the Pennsylvania Society of Be-
havioral Medicine and Biofeedback; and a member of the American
Psychological Association; the American Psychosomatic Society;
and the Academy of Psychosomatic Medicine.
CONTENTS
Foreword xi
Hugo Twaddle, MD
Preface xiii
Organization of the Book xiv
Acknowledgments xvii
Introduction 1
PART I: THEORETICAL ASPECTS OF CHRONIC PAIN

AND STRESS
Chapter 1. Fibromyalgia Pain Syndrome:
A Brief Review of the Literature 9
Depression and Anxiety As Concomitants
of Fibromyalgia 14
Fibromyalgia and Sleep Disturbance 15
Fibromyalgia and Myofascial Pain Syndrome 16
Physical Criteria for the Diagnosis of Fibromyalgia 17
Treatment Interventions 19
Biofeedback, Relaxation Therapy, and Hypnosis 20
Physical Therapy Interventions 22
Fibromyalgia and Psychobiological Disregulation 23
Chapter 2. Stress and Pain 25

The Concept of Stress 26
Models of Stress 27
Psychophysiology of Stress 32
Chapter 3. Methods of Stress Management 37

Stress Management Techniques 37
Models of Relaxation 48
Summary 51
PART II: HISTORY AND PRINCIPLES OF AUTOGENIC
TRAINING
Chapter 4. Autogenic Training:
Its History and Basic Principles 55
The Birth of Autogenic Training 55
Elements of the Autogenic Process 59
Conclusions 61
Chapter 5. Autogenic Training:

Medical and Psychological Screening 63
Medical Screening 63
Psychological Screening 65
Chapter 6. Requirements for Achieving

the Autogenic State 67
Lessons from Restricted Environmental Stimulation
Therapy 68
Restricted Environmental Stimulation and Stress
Management 69
The First Requirement: Reducing Environmental
Stimulation 70
The Second Requirement: Passive Concentration 75
The Third Requirement: Making Mental Contact
with a Specific Body Part or Function 78
The Fourth Requirement: Repetition of Specific
Phrases (Formulas) 79
The Fifth Requirement: Daily Practice 80
Quick Summary 81
PART III: TRAINING, BIOFEEDBACK,
AND TREATMENT OF INSOMNIA
Chapter 7. The Preliminary Exercises 85
General Instructions 85
Preliminary Exercise I 86
Preliminary Exercise II 90
Remarks 93
Chapter 8. The First Standard Exercise: Heaviness 95
Introducing the First Exercise 95
The Brief Exercise 99
The Extended Exercise 100
Common Difficulties with the First Standard Exercise 102
Case Example 103
Chapter 9. The Second Standard Exercise: Warmth 105

The Warmth Exercise 107
Common Difficulties with the Second Standard Exercise 109
Case Example 110
Chapter 10. The Third Standard Exercise: Heart 113

The Heart Exercise 115
Common Difficulties with the Third Standard Exercise 116
Case Example 117
Chapter 11. The Fourth Standard Exercise: Respiration 119

The Respiration Exercise 122
Common Difficulties with the Fourth Standard Exercise 123
Case Example 124
Chapter 12. The Fifth Standard Exercise:

Abdominal Warmth 127
The Abdominal Warmth Exercise 132
Common Difficulties with the Fifth Standard Exercise 134
Case Example 135
Chapter 13. The Sixth Standard Exercise:

Forehead Cooling 137
The Forehead Cooling Exercise 139
Common Difficulties with the Sixth Standard Exercise 141
Case Example 142
Chapter 14. Advanced Autogenic Training 145
The Abbreviated Sequence for Replenishment 146
The Use of the Organ-Specific Formulas 148
The Use of the Intentional Formulas 149
The Technique of Autogenic Meditation 150
Meditative Exercise 1: Automatic or Spontaneous
Visualization of Colors 152
Meditative Exercise 2: The Visualization of Suggested
Colors 153
Meditative Exercise 3: The Visualization of Definable
or Concrete Objects 155
Meditative Exercise 4: The Visualization of Certain
Concepts 157
Meditative Exercise 5: The Experience of a State
of Feeling 159
Meditative Exercise 6: Visualization of Other People 159
Meditative Exercise 7: The Insight Meditation 160
Some Final Thoughts About the Meditative Exercises 161
Case Example 162
Chapter 15. Autogenic Training and Biofeedback 165
What Is Biofeedback? 166
What Is Autogenic Biofeedback? 167
Are Biofeedback Instruments Necessary
for Autogenic Training? 169
Chapter 16. Sleep, Insomnia, and Pain 171
The Stages of Sleep 172
Reducing Cognitive Anxiety 175
Improving Sleep 178
Autogenic Training and Sleep 181
Chapter 17. Questions and Answers 185
Appendix A. The Autogenic Pain and Tension Checklists 191
Appendix B. The Autogenic Training Progress Index 197
References 201
Index 211
Foreword
I first studied autogenic training under the auspices of Dr. Durand

de Bousingen, professor of medicine and psychiatry at Universite
Louis Pasteur Faculte de Medicine, in France. Dr. Bousingen, who
had received his training from Dr. Johannes Schultz, the founder of
autogenic training, treated a number of psychiatric and medical con-
ditions by means of autogenic training. In his lectures, the professor
often discussed and illustrated the therapeutic benefits of this psycho-
physiologically based treatment modality with documented preven-
tative qualities.
It took me approximately six weeks to learn the basics of the tech-
nique and soon its replenishing qualities became very evident to me.
After a period of regular practice, rather spontaneously, I began to ex-
perience some of the more advanced stages of autogenic meditation
that promote profound psychophysiological recovery from stress.
Even to this day, as a physician with a very busy schedule, I have
found that this remarkable technique prolongs my focus and refur-
bishes my energy. The self-recuperative benefits of autogenic train-
ing can be literally summoned in a matter of minutes once certain
guidelines are observed, especially the need for daily practice. Such
benefits have been documented in the annals of medicine and psy-
chology for decades and it is important that we heed them.
The six standard autogenic exercises and the advanced meditative
techniques have been taught in medical schools throughout Europe
for some time. It is indeed regrettable that in the United States we
have not yet fully explored the therapeutic benefits of this research-
based, time-tested form of psychophysiological therapy. A potent
therapeutic technique such as autogenic training is especially critical
in the treatment of chronic and stress-related conditions. These con-
ditions require a multidisciplinary treatment approach with specific
focus on mind-body interactions, most importantly in terms of nor-
malizing the activities of the autonomic nervous system. Further-
more, it is critical to recognize and address ineffective and maladaptive
xi
xii AUTOGENIC TRAINING
behaviors by providing patients with more healthy and constructive

therapeutic techniques. Special attention needs to be paid to those in-
terventions that, under initial supervision, patients can learn and then
practice on their own. This move toward further autonomy can serve
an important therapeutic role, namely empowering the patient. This
critical goal cannot be achieved by merely medicating the patient.
Dr. Micah Sadigh has devoted a major part of his professional life
to understanding and enhancing the autogenic technique through re-
search and clinical practice. For many years, he has been tackling
some of the most challenging chronic conditions by incorporating
autogenic principles, techniques, and therapeutic modalities into pa-
tients’ treatment protocols with much success. In this book, not only
does he present the original technique, but additional elements that
can improve the achievement of the autogenic state are included. He
has also addressed some of the more advanced facets of the tech-
nique, such as autogenic meditation and autogenic modifications.
Although the training can be of significant therapeutic value to any-
one who is suffering from the deleterious effects of exposure to pro-
longed stress, it should also prove particularly valuable to people who
suffer from chronic pain syndrome, fibromyalgia pain syndrome, and
chronic fatigue immune deficiency syndrome. As it was pointed out,
these difficult and complex clinical conditions require a multidisci-
plinary approach to treatment, especially psychophysiological inter-
ventions that can be learned by patients so that they can be empowered
and gain greater control over these potentially devastating conditions.
As physicians and clinicians we need to take the necessary steps to
help our patients achieve quality of life. Autogenic training can play
an important role to this end. Dr. Sadigh’s book is a welcome addition
to the clinical resources of those who have dedicated their lives to
helping patients with chronic pain to reduce their suffering and to live
more fulfilling lives. The detailed, step-by-step guidelines provided
in this book afford the clinician the benefit of effectively teaching the
basic technique as well as its additional therapeutic modalities with
great ease and focus.
The publication of such a comprehensive and effectively written
book on autogenic training has been long overdue.
Hugo Twaddle, MD
The Lehigh Valley Hospital Network
Preface
My exploration of autogenic training began in 1979 when I was

taking a course in psychophysiology and biofeedback. After reading
dozens of papers about this technique and its medical and psycholog-
ical applications, I became so intrigued that I decided to make a major
investment and purchase the six “classic” volumes on autogenic ther-
apy. These volumes consisted of autogenic methods, medical appli-
cations, applications in psychotherapy, research and theory, dynamics
of autogenic neutralization, and treatment with autogenic neutraliza-
tion. The wealth of clinical and empirical knowledge in these vol-
umes was so prolific that it took several years to read them.
It has been over twenty years since those days, and autogenic train-
ing has continued to be a steady and important part of my profes-
sional life. After years of conducting research with this technique, I
began using it to treat patients with chronic pain (including fibro-
myalgia and chronic fatigue) and stress-related conditions. In addi-
tion, I found the technique to be of immense value in treating a
variety of recalcitrant sleep-related conditions.
Throughout the years, I have found the autogenic technique to be a
superior psychophysiological intervention, especially when used in
the context of a multidisciplinary approach to pain management.
Most patients not only report an improvement in their ability to cope
with persistent pain, they almost invariably notice cognitive and emo-
tional changes that are consistent with a replenishment of their physi-
cal and psychological resources. A steady improvement in sleep
quality is without a doubt a hallmark of autogenic training. Because
sleep loss is one of the main complaints of most chronic pain suffer-
ers, the clinical benefits of this intervention cannot be overempha-
sized.
Thousands of published studies attest to the therapeutic effects of
autogenic training. However, except for the six classic volumes men-
xiii
xiv AUTOGENIC TRAINING
tioned previously, few books have been written on this topic, and
none about its use in treatment of chronic conditions. Unfortunately,
the coverage of autogenic training in books on relaxation therapy is
so basic (usually one or two pages on heavy and warm phrases) that it
is unlikely to produce any therapeutic results. Even worse, such
overly general instructions may potentially bring about paradoxical
and adverse therapeutic results.
The main purpose of writing this book is to present practitioners
with a concise exploration of autogenic technique and its clinical use,
especially in treating those suffering from chronic pain syndrome and
fibromyalgia pain syndrome. Furthermore, the training principles pre-
sented here can be effectively used to treat a variety of stress-related
conditions. As it will be emphasized throughout the book, patients re-
ceiving autogenic training need to be under close medical supervi-
sion because of its potent and dynamic therapeutic nature. For this
reason, a chapter has been dedicated to medical and psychological
screening, which I highly recommend that practitioners review prior
to assessing patients for this training.
ORGANIZATION OF THE BOOK
The book is divided into three sections. The first section consists of
chapters that address theoretical aspects of the treatment of chronic
pain and fibromyalgia. Here special attention is paid to the connec-
tion between stress and chronic pain. A chapter is dedicated to the re-
view of the literature on fibromyalgia and its treatments. In addition
to autogenic training, a variety of established mind-body techniques
which purport to affect pain are also discussed.
In the second section, detailed information is provided about
autogenic training, including its history and clinical formulations.
Chapters are dedicated to requirements for effective training and
medical and psychological screening.
Finally, the third section consists of a detailed, step-by-step man-
ual for autogenic training. The rationale for each component of train-
ing is provided prior to instructions for each exercise. Each chapter
concludes with an actual case presentation that illustrates the use of
autogenic training in a variety of mind-body conditions. Several
Preface xv
chapters are dedicated to advanced autogenic training, autogenic bio-

feedback, and the treatment of insomnia. This section concludes with
some of the most commonly asked questions about autogenic train-
ing and their answers.
I hope that practitioners and students will find the book helpful in
exploring the many benefits of autogenic training as an effective
treatment for chronic pain and fibromyalgia. Ultimately, it is our task
to help our patients gain greater control over their symptoms and to
assist them with tools to improve coping and to reduce suffering. A
time-tested technique such as this should prove to be of significant
therapeutic value.
To those friends and colleagues who encouraged me and have in-
cessantly reminded me of the benefits of writing this book, I owe
my gratitude. Finally, I wish to quote a tribute originally given to
the great Dr. Paul Ehrlich. This sentiment applies to the father of
autogenic training, Dr. Johannes Schultz and his tireless protégé,
Dr. Wolfgang Luthe, as well.
Was vergangen kehrt nicht wieder,

Aber ging es leuchtend neider,
Leuchtet’s lange noch Zuruck.
What has passed will never return,
But if it sank in dazzling flame,
Flashes of light will still remain.
as quoted in Marquardt, 1949

Acknowledgments
This is a tremendous opportunity to express my gratitude to my

teachers and friends without whom the writing and publication of this
book would not have been possible. I am indebted to Dr. Richmond
Johnson, who introduced me to the wondrous world of psychology
and psychophysiology during my undergraduate training at Moravian
College. It was in his course in applied psychophysiology that I was
introduced to autogenic therapies. Dr. Johnson also supervised my
first scientific study on the treatment of migraine headaches with
autogenic training, which we presented in 1981. I was also blessed
with wonderful mentors while I was completing my graduate work at
Lehigh University. I am especially grateful to Dr. John Mierzwa, Dr.
William Stafford, and Dr. Debra Finnegan-Suler.
My clinical training in pain management would not have been
complete without the privilege of working with my teacher and
friend, the respected surgeon, Dr. Peter Kozicky.
I also cherish the moments I spent with my friend and colleague,
Daniel Danish, whose wisdom and experience, especially in the treat-
ment of the fibromyalgia pain syndrome, have always inspired me.
I wish to express my thanks to my colleagues and friends at Good
Shepherd Rehabilitation Hospital, especially the members of the pain
management team. I want to extend heartfelt gratitude to my good
friends and dedicated clinicians, Anne Schubert, Marcus Weber (De-
partment of Physical Therapy), and Dr. Rick Schall (Department of
Psychology) for their helpful comments and encouragement during
the preparation of the manuscript.
My heartfelt gratitude is extended to The Haworth Press, espe-
cially to Peg Marr, Senior Production Editor, and her splendid staff
for all of their hard work, their kindness, and their invaluable contri-
butions during the editing process. It was truly a pleasure working
with such a remarkable group of people.
xvii
xviii AUTOGENIC TRAINING
To my wonderful students at Cedar Crest College, I owe special

thanks for their contagious enthusiasm, dedication, and their inspir-
ing desire to learn.
Finally, this book would not have been possible without the steady
support, love, and encouragement of my dear wife Michelle who sac-
rificed much to give me the time for researching and writing.
Micah R. Sadigh, PhD

Bethlehem, Pennsylvania
Introduction
The nineteenth-century revolution in medicine brought about sig-

nificant changes in the conceptualization of causes of disease and the
search for effective treatments. Louis Pasteur’s Germ Theory placed
emphasis on the invisible, microorganismic causes of sickness and
death.
Other great scientists such as Rudolf Virchow asserted that disease
was ultimately caused by defects in cells and organs of the body.
Omnis cellula e cellula, or all cells come from cells, became a con-
vincing argument to explore tissue pathology to understand the cause
of disease. Such linear and mechanistic views about the nature of
sickness became the very core of the revolution in medical science
and persist with some degree of determination to this day (Weiner,
1977).
Among the great minds of the nineteenth and the early twentieth
century medicine was Paul Ehrlich, a man who has been viewed by
many as the father of chemotherapy. He introduced the curative med-
ical model based on the infectious and the cellular pathology models.
Ehrlich believed that if the pathogenic origin of a disease was known,
then the effective cure was only a matter of discovering the right
chemical combination to eradicate the disease-generating pathogene.
He referred to such curative chemical substances as “magic bullets.”
After years of tireless work, his idealistic views became a reality as
he developed the compound 606, an arsenic derivative which was
used effectively to treat and cure the dreadful epidemic of neuro-
syphilis. The ingenious magic bullet concept has resulted in the dis-
covery of innumerable compounds that have saved millions of lives.
At the same time, it has plagued the Western world with the idea that
for every disease there must be a magic bullet, a curative pill, or injec-
tion. While Ehrlich’s model has proven its effectiveness in the treat-
ment of many diseases, it has serious limitations, especially when
applied to the treatment of chronic and disabling conditions. It also
1
2 AUTOGENIC TRAINING
fails to account for psychological, environmental, and stress-related

contributors to the development of disease and physical breakdown.
When it comes to the treatment of chronic conditions, unfortunately,
there are no “magic bullets.”
After decades of research, Engel (1977) introduced the biopsycho-
social model of medicine, which has gained much recognition since its
inception. This nonlinear model emphasizes that to understand the na-
ture of disease and illness one must recognize the intimate interdepen-
dence and interactions among genetic, biological, psychoemotional,
cognitive, behavioral, and sociocultural variables and processes. “The
biopsychosocial model is a scientific model constructed to take into ac-
count the missing dimensions of the biomedical model” (Engel, 1980,
p. 535).
Persistent and recalcitrant conditions such as chronic pain syn-
drome, fibromyalgia pain syndrome, and chronic fatigue immune defi-
ciency syndrome can best be understood from a biopsychosocial perspec-
tive since these conditions are multifactorial in nature and involve
many complex variables. The traditional biomedical model with its
focus on microorganismic and pathophysiological concepts is too
limiting when it comes to the assessment, evaluation, and treatment
of the aforementioned clinical entities. These system-wide condi-
tions require a multidisciplinary approach with focus on coping and
effective symptom management.
Haddox (1997) suggested that since the traditional, biomedical ap-
proach is not sufficient in effectively treating patients with chronic
pain, the biopsychosocial model may be more applicable when ad-
dressing the needs of this population. Since one of the most important
goals of pain management is to improve quality of life, rather than a
one-dimensional goal of pain erasure, a more integrated treatment
approach is required (Engel, 1977). The biopsychosocial model ex-
plores “physical (biomedical) aspects, psychological characteristics
(e.g., behaviors, personality traits, coping styles, cognition, affective
disturbances), and social features (e.g., employment history, job sat-
isfaction, compensation status, role reversal) [of the patient]” (Haddox,
1997, p. 189). For instance, in recent years, a number of studies have
suggested that when it comes to the assessment and treatment of
chronic conditions, it is critical to consider how personality styles
and disorders may affect coping (Sadigh, 1998). A study by Polatin
Introduction 3
and colleagues (1993) found a high prevalence of personality disor-

ders (over 51 percent) in a population of chronic back sufferers.
Hence, by recognizing personality factors, clinicians can more effec-
tively design treatment packages and programs that can be most ben-
eficial to the patient.
Clearly, any chronic condition poses a challenge to clinicians who
attempt to provide a treatment strategy with the hope that it will re-
duce anguish and help those affected live with fewer limitations. One
of the most critical dimensions of chronic pain, and for that matter
any other persistent condition, is the experience of suffering, which
often involves the realization that there may be no relief in sight. Suf-
fering can result in the experience of anxiety, depression, and learned
helplessness, especially when the cause of the persistent symptoms,
such as pain, is uncertain. Leshan (1964) stated that chronic pain pa-
tients live their waking hours in a nightmare because of the continual
experience of having no control and helplessly wondering what may
happen next. This is the type of a nightmare from which one cannot
easily wake. Tollison (1998) further emphasizes this point by stating
that “no one dies from benign [chronic] pain, but many victims suffer
a disabled and pleasureless existence. In addition, an alarming per-
centage of severly afflicted chronic pain patients have no interest in
longevity and instead await death and its end to suffering with antici-
pation” (p. 3).
When people recognize that their attempts at relieving suffering
have failed, they begin to withdraw and isolate themselves as their
very sense of self begins to fragment. According to Seligman (1975),
the experience of learned helplessness is likely to have motivational,
cognitive, and emotional consequences that may threaten the very in-
tegrity of the person. Reestablishing some sense of control over the
persistent symptoms becomes of paramount importance in reducing
suffering. Current studies suggest that by improving coping skills, it
may be possible to reestablish the lost sense of control and to amelio-
rate reactive depression (Blanks and Kerns, 1996).
Within the context of the biopsychosocial model of pain manage-
ment, psychophysiological techniques play an important role in the
treatment process, and once combined with other interventions, they
can bring about significant changes in the overall functioning of the
patient, reduce helplessness, and increase self-efficacy. Gallagher
(1997) suggested that such techniques can significantly affect pain

perception by reducing biomechanical strain, and by significantly af-
fecting neuropathic pain generators. A panel of the National Institutes
of Health that explored the efficacy of relaxation techniques in the
treatment of chronic pain concluded that “There is strong evidence
that relaxation techniques (e.g., deep and brief autogenic training,
meditation, progressive muscle relaxation) are effective for the treat-
ment of a variety of medical conditions, including chronic pain. . . .
Relaxation techniques as a group generally relieve pain by altering
sympathetic nervous system activity as indicated by decreases in oxy-
gen consumption, respiration, heart rate and blood pressure” (Berman,
1997, p. 172).
Among the various psychophysiological therapies for pain manage-
ment is a well-recognized, empirically based technique, autogenic
training, which was developed by the respected neuropsychiatrist,
Johannes Schultz. For over seventy years, autogenic training has been
used throughout the world, especially in the treatment of chronic and
stress-related conditions. Literally thousands of published studies sup-
port the effectiveness of this technique in enhancing the body’s self-re-
cuperative mechanisms.
Perhaps one of the most concise descriptions of autogenic training
was stated by Wolfgang Luthe, Schultz’s most prominent protégé, in
the following words:
One of the most important assumptions of autogenic training is

that nature has provided man with homeostatic mechanisms not
only to regulate fluid and electrolyte balance, blood pressure,
heart rate, wound healing and so on, but also to readjust to more
complicated functional disorders that are of a psychophysio-
logical nature. In autogenic training the term “homeostatic self-
regulatory brain mechanism” is often used. This concept as-
sumes that when a person is exposed to excessive, disturbing
stimulation (either physical, or emotional), the brain has the po-
tential to utilize natural biological processes to reduce the dis-
turbing consequences of the stimulation (i.e., neutralization). At
the mental level, some of this self-regulatory neutralization or
recuperation occurs naturally during sleep and dreams. The
techniques developed and used in autogenic training have been
Introduction 5
designed to support and facilitate the natural self-healing mech-

anism that already exists. (Luthe, 1977, p. 2)
In a sense, this technique simply activates, supports and enhances

the body’s inherent repair mechanism duplicating what happens in
the deeper stages of sleep when the body is provided with a chance to
renew its resources. Also, as it will be explored in the chapter on sleep
(Chapter 16), most people with chronic conditions suffer from a lack
of quality sleep, i.e., they are sleep deprived. Since we cannot simply
induce entry into deeper stages of sleep and hope that patients will re-
ceive the needed rest, we need to rely on techniques such as autogenic
training that promote a state of repair. Interestingly, as the body’s re-
sources are replenished, a greater likelihood for entering deeper sleep
and benefiting from quality rest is observed.
Autogenic training not only has the potential to assist individuals
in coping with persistent pain, it also improves their emotional, cog-
nitive, and psychological functioning (Luthe, 1973). Also, as men-
tioned, one of the most devastating concomitant of any chronic
condition, the state of “helplessness” can be addressed through this
technique by empowering individuals to gain greater control over
their symptoms with greater efficiency. Hence, suffering and depres-
sion are reduced as a greater sense of self-mastery begins to emerge.
As I note throughout the book, autogenic training is a most potent
treatment for chronic conditions primarily because it is based on a
sound theoretical formulation that emphasizes activating the body’s
potential for repair and regeneration. Clinical and experimental data
collected from years of research have supported the many theoretical
and clinical premises of this technique.
One of the greatest values of the autogenic technique is that once it
is mastered, its therapeutic effects can be summoned relatively quickly.
Once individuals realize that through regular practice they can effec-
tively reduce their suffering, the recovered sense of hope will, by it-
self, help them to improve their coping abilities and is likely to
remind them that they have at least some control over their pain and
suffering. As this sense of control begins to evolve, other physiologi-
cal, psychological, and interpersonal changes are apt to occur.
At this point it needs to be emphasized that autogenic training is
only one intervention within a multidisciplinary approach to pain
management—it is by no means a panacea and it cannot replace other
therapeutic approaches such as pharmacotherapy, physical therapy,

and psychotherapy. As will be discussed, there are certain conditions
for which autogenic training is not indicated. For example, in the case
of severe depression, psychopharmacologic agents combined with
psychotherapy are more appropriate interventions. Once the depres-
sion is more effectively managed, the training may commence in con-
junction with other therapies.
The great Swiss physician, Paracelsus, often reminded his students
that the greatest medicine a physician could offer his patients was
hope. Therefore, as practitioners, we need to do whatever is neces-
sary to renew a sense of hope within those we treat. In pages to come,
the autogenic technique and its adjunctive methods will be discussed
in some detail. The most potent therapeutic techniques, however, can
only make a difference if they are practiced with consistency and per-
severance. Perhaps one of the most effective methods of motivating
others is to be a good role model. I recommend that the readers of this
text begin regular practice of the technique as a way of learning its in-
tricacies and benefits to more effectively engender a sense of motiva-
tion within their patients.
PART I:
THEORETICAL ASPECTS
OF CHRONIC PAIN AND STRESS
Chapter 1
Fibromyalgia Pain Syndrome:

A Brief Review of the Literature
Chronic pain is a complex phenomenon that can have profound

physical, emotional, psychological, interpersonal, and even societal
implications. It is a multidimensional phenomenon, a puzzle that re-
quires further scientific scrutiny and analysis (Sadigh, 1990). One of
the basic characteristics of chronic pain is that in most cases, it does
not serve a biological purpose, unlike acute pain which many be con-
sidered a survival mechanism, often signaling tissue damage, and/or
a need for rest and convalescence (Sternbach, 1983). Bonica (1992)
and Haddox (1997) estimated the overall cost of treatment of chronic
pain to be somewhere between 68 and 70 billion dollars annually.
They further suggest that approximately 550 million workdays are
lost in the United States on a yearly basis due to ongoing pain.
Cousins (1995) found that the dollars spent annually to treat chronic
pain by far exceed the costs of treating heart disease, cancer, and
AIDS. These staggering figures appear to be on the rise as medical
science struggles to better understand the enigma of chronic pain.
In recent years, clinicians and researchers alike have been involved
in further exploring, understanding, and treating a chronic form of
muscular pain often referred to as fibromyalgia (previously referred
to as fibrositis), whose etiology remains poorly understood. While
fibromyalgia is a relatively new term and a recent diagnostic concept,
the condition itself has been recognized by physicians and medical
researchers for some time. It has been estimated that close to six mil-
lion Americans suffer from fibromyalgia syndrome and the most
conservative estimates suggest that the cost to the economy is close to
9
10 billion dollars annually (Russell, 1994). Currently, fibromyalgia

(FM) is one of the most widely treated conditions in a rheumatology
practice.
Sometime between 1850 and 1900, German authors began describ-
ing a peculiar musculoskeletal condition which they called “Muskel-
harten” or hard muscles (See Simons, 1975). A few years later, in
1904, the respected physician William Gowers introduced the con-
cept of fibrositis which suggested that the enigmatic musculoskeletal
symptoms were due to an inflammation of the fibrous tissue, hence
the term fibrositis. Although this term has been used by physicians,
and especially rheumatologists, for nearly a century, medical re-
searchers have found little use for its clinical applications due to the
absence of a true inflammatory condition that could explain the na-
ture of the muscular symptoms. In recent years, this diagnosis has
fallen out of favor within the medical community and is rarely used as
a diagnosis for widespread, noninflammatory muscle pain (Golden-
berg, 1992).
It is helpful to note that on many occasions, both among research-
ers and medical practitioners, fibrositis became synonymous with
“psychogenic rheumatism,” an erroneous formulation which took
years to shed. Semble and Wise (1988) defined psychogenic rheuma-
tism as a psychiatric condition with significant emotional and psy-
chological difficulties and bizarre and inconsistent symptoms. People
with this condition were observed to have almost a startle response to
mild touch or pressure when it was applied to certain body parts.
Even today, there are still those who continue to espouse a psychiatric
approach in the treatment of FM.
In an extensive review of the literature on the psychological and
the psychiatric aspects of fibromyalgia pain syndrome, Yunus (1994b)
made the following remark, “Many physicians believe, from the early
years of their training, that a ‘true’ disease is based on pathological
changes in the tissue. Macroscopic and microscopic visualization of
such changes form the core of this traditional model. Any disease,
condition or syndrome which fails to show these findings has been
considered to represent a psychological entity . . .” (p. 811). Indeed,
the current literature fails to show that FM is a psychiatric disorder.
Although patients suffering from this condition at times show
above average levels of anxiety and may present with clinical depres-
Fibromyalgia Pain Syndrome: A Brief Review of the Literature 11
sion, these are naturally expected symptoms when one considers the
profound changes that any chronic condition can bring about in the
life and the psychological state of the sufferer. Depression, for exam-
ple, is often experienced by chronic pain patients and is the result of
both neurohormonal changes as well as the experience of helpless-
ness when dealing with a condition that does not readily respond to
common, medical interventions. Current studies have failed to show
a strong link between fibromyalgia and predisposing psychiatric con-
ditions. There is clearly a need for longitudinal studies to fully ex-
plore such possible links.
Neurasthenia was another term used at times to describe what we
refer to as fibromyalgia. This term has also been used extensively in
the literature regarding chronic fatigue syndrome. However, since the
majority of patients with fibromyalgia present with symptoms of fa-
tigue, it may be helpful to explore the historical origins of neurasthe-
nia and its clinical features.
The American physician, George Beard (1869), coined the term
“neurasthenia,” which means nervous exhaustion or a lack of nerve
strength, as a way of describing a peculiar disease of the industrial
world which was the result of exposure to prolonged stress and envi-
ronmental toxins. According to Beard, regardless of rest and sleep,
the neurasthenic was unable to regain his strength and vitality. Almost
fifty years before the diagnosis of chronic fatigue was introduced by
the Centers for Disease Control (Holmes et al., 1988), the respected
physician and author William Sadler wrote, “In the last analysis,
neurasthenia is to be defined as a state of accumulated chronic fa-
tigue” (p. 114). Here are some of the symptoms of neurasthenia as
cataloged by Gray (1978): “persistent musculoskeletal pain, tender-
ness of the entire body, insomnia, fatigue, irritability, abnormal dryness
of the skin, vertigo and dizziness, memory and concentration prob-
lems, lack of decision making in trifling matters, numbness, tender-
ness of the entire body, difficulty swallowing, noises in the ear, and
sweating hands and feet” (p. 206).
It is interesting to note that during the 1930s and 1940s a large
number of explanations for the possible causes of neurasthenia emerged
from fields of medicine, psychology, psychiatry, and sociology. These
explanations ranged from unresolved intrapsychic conflicts, unknown
microorganismic infections, food that was devoid of essential nutri-
ents, to cultural and religious changes. It was believed that certain

cultural and religious beliefs that once served to suppress some of the
day-to-day anxieties and worries were less relied upon, which made
people more vulnerable to life’s uncertainties. Too much brain activ-
ity and too little time for rest and recuperation was one prevailing for-
mulation for this condition. Even today many fibromyalgia and
chronic fatigue patients attest to an inability to “shut down” or quiet
their thinking, especially late at night as their hope to gain some rest
from the nightly slumber eludes them. Some of the most common
treatments that were prescribed for nervous exhaustion included
better nutrition, better air, relaxation, recreational activities, and one
that was endorsed by many physicians and which solely relied on the
patient: lifestyle changes.
Although American physicians have abandoned the use of this
term as a valid diagnosis, many European and especially Chinese
physicians find the concept quite helpful both for diagnostic and
treatment purposes. “Nervous exhaustion” makes a great deal of
sense to the practitioners of oriental medicine who view symptom
manifestation as a result of a drop in the vital bodily energy. In East-
ern countries, a combination of herbal remedies and acupuncture is
used to restore the body’s resources.
As mentioned earlier, while musculoskeletal pain, both wide-
spread and diffuse, is an integral part of fibromyalgia syndrome, it
seems to be accompanied by a number of other specific conditions
such as fatigue, headaches, malaise, gastrointestinal distress, sleep
disorder, and oversensitivity to weather conditions (e.g., heat and
cold) (Semble and Wise, 1988). Clauw (1995) pointed out that pa-
tients may also present with symptoms such as abnormal movements
of the eyes (ocular dysmotility) and sensitivity to noise and light, as
well as difficulties with balance due to vestibular abnormalities. In
addition, a large number of fibromyalgia patients (approximately
70 to 80 percent) appear to have indications of mitral valve abnormal-
ities which are supported by echocardigraphic studies (Pellegrino et
al., 1989). Simons (1976) asserted that the presence of specific tender
points constituted a major diagnostic feature of this syndrome (then
called fibrositis). A major study undertaken by Campbell and his col-
leagues (1983) clearly demonstrated that fibromyalgia patients had
significantly more distinguishable tender points than those in the

control group.
Based on the review of a number of studies, Adams and Sim
(1998) listed other symptoms of fibromyalgia, such as “a sensation of
muscle tension and morning stiffness, chronic headaches (tension or
migraine), irritable bowel syndrome, . . . jaw pain, microcirculatory
disorders such as Raynaud’s syndrome, and postexertional muscle
pain, etc” (p. 307). Yunus (1994a) stated that over 50 percent of fibro-
myalgia patients complain of a swollen feeling, mostly in the upper
extremities, and paraesthesia in both the upper and the lower extremi-
ties. Such sensations are primarily subjective in nature and often are
not substantiated by neurological studies, while at the same time they
do not appear to have a psychological origin either. Unknown, under-
lying biochemical changes may be contributing to the experience of
such sensations. Finally, significant premenstrual symptoms and dis-
tressing urinary difficulties are also reported by these patients (Yunus,
1994a).
In another study, Leavitt, Kantz, and Golden (1986) investigated
the presence of tender points in both fibromyalgia and rheumatoid ar-
thritis patients. Their study confirmed that pain affected multiple
sites in both groups with fibromyalgia pain being more widespread
and less localized than in the arthritis group. In the same study, the in-
vestigators used a modified version of the McGill Pain Questionnaire
to further evaluate differences between the two groups. Their find-
ings suggested that the fibromyalgia subjects were more likely to use
more diverse descriptors of pain to define and characterize their pain
as compared to patients with rheumatoid arthritis.
Yunus, Masi, and Calabro (1981) discovered that fatigue was one
of the most prevalent symptoms of fibromyalgia. Their study showed
that over 90 percent of their sample of fifty-two fibromyalgia patients
suffered from fatigue, whereas this symptom was predominant only
in 10 percent of the normal subjects (Yunus, 1994a). Similar studies
have also hinted that gender may play a role in this disorder. Accord-
ing to Goldenberg (1992), fibromyalgia appears to be more prevalent
in women than in men. A greater understanding of gender as a possi-
bly contributing variable is necessary to allow a better formulation of
the etiology and the pathophysiology of fibromyalgia.
DEPRESSION AND ANXIETY

AS CONCOMITANTS OF FIBROMYALGIA
As it was mentioned earlier, depression is often a concomitant of

chronic pain. This appears to be especially true with the fibromyalgia
pain syndrome. Several studies have documented a higher prevalence
of depression in patients suffering from fibromyalgia and rheumatoid
arthritis than in controls (Goldenberg, 1989a; Wolfe, Cathey, and
Klienheskel, 1984). Similarly, patients with fibromyalgia showed
higher rates of anxiety disorder and significantly higher rates of major
depression when compared with a rheumatoid arthritis group (Hudson,
Hudson, and Pliner, 1985). Yunus (1994b), however, argues that some
of these studies suffer from methodological problems, and higher rates
of depression and anxiety may be true only in a subgroup of FM pa-
tients. Further studies with better controls are needed to more accu-
rately investigate these issues.
Goldenberg (1989b) emphatically stated that in spite of the pres-
ence of depression and anxiety in fibromyalgia patients, most of them
do not have a psychiatric diagnosis. The experience of depression and
anxiety in any chronic condition may be attributed to a growing state
of learned helplessness which is often exaggerated by the patients’
desperate attempts at conquering the pain.
Furthermore, stress appears to play an important role in worsening
the symptoms of fibromyalgia (the topic of stress will be explored in
detail in Chapter 3). Again this is not an unusual finding since most
chronic pain conditions seem to be exacerbated by stress (Sadigh,
1990). Rice (1986) suggested that fibromyalgia patients may exhibit
stressful “fibrositic personality” with characteristics such as being
demanding, perfectionistic, driven, and highly ambitious. It is impor-
tant to note that many fibromyalgia patients appeared to have had sig-
nificantly more stress and/or experiences of stressful life events prior
to the onset of their symptoms (Wolfe, 1986). Such findings may sug-
gest an exhaustion of biochemical resources that in time may contrib-
ute to the pathogenesis of this syndrome.
FIBROMYALGIA AND SLEEP DISTURBANCE
Another common complaint of patients suffering from this syn-

drome is sleep disturbance and a lack of quality sleep. Several studies
have documented that fibromyalgia patients tend to have abnormal
non-rapid eye movement (NREM) sleep, usually consisting of alpha
wave intrusion or reduced Stage 4 sleep (delta sleep) (Moldofsky et al.,
1975). In a pioneering study, Moldofsky and colleagues (1975) were
able to induce increased muscle stiffness and aching in normal volun-
teers by depriving them of delta sleep. Although the biochemical
changes occurring during Stage 4 sleep remain poorly understood, a
serotonergic connection does appear to be a key factor that promotes
a restorative process in this stage of sleep (Moldofsky and Lue,
1980). This is perhaps why tricyclic antidepressants such as doxepin
and amitriptyline, which promote an increase in the serotonin levels
within the brain, have shown therapeutic promise in the treatment of
this syndrome (Jouvet, 1969; Goldenberg, 1992). Elsewhere, Russell
(1989) found that serum levels of serotonin were significantly lower
in fibromyalgia patients than in healthy controls. As Clauw (1995)
has pointed out, the serotonin connection deserves further investiga-
tion because abnormalities in this hormone are also seen in patients
with migraine headaches, those suffering from depression, and also
in patients with colitis. Also, an increase in serotonin levels can bring
about an improvement in the digestive tract, weight loss through a de-
crease in a desire for consumption of foods rich in carbohydrates
(Courmel, 1996), and as mentioned earlier, sleep latency and sleep
maintenance are substantially enhanced with increased serotonin
availability.
Deficiencies in neurotransmitters, such as serotonin and norepi-
nephrine have also been shown to bring about a drop in the pain thresh-
old and consequently may result in a greater sensitivity to pain. These
findings further suggest the potential importance of various neuro-
transmitters in fibromyalgia and the chronic pain syndrome.
Bennett and colleagues (1992) found abnormalities in other hor-
mones such as somatotropin (growth hormone) and somatotropin C
in FM patients. The growth hormone, which seems to reach its peak
production in deep sleep, is necessary for repair and regeneration of
muscles and joints. Somatomedin C (produced in the liver), whose
production is intimately linked to somatotropin and is similar to insu-

lin, plays a critical role in metabolic functions. Current studies are
further exploring the abnormally low levels of these hormones in
some FM patients and possible causes of such changes. Bennett and
Walczyk (1998) treated a group of women with fibromyalgia with
growth hormone injections and noticed a significant improvement in
their overall symptoms, including a significant reduction in the num-
ber of the tender points.
Finally, it should be emphasized that sleep deficiency alone does
not appear to be the cause of this condition. Some of the abnormal
sleep patterns seen in fibromyalgia patients have also been docu-
mented in patients with other conditions who did not seem to suffer
from persistent musculoskeletal pain. This clearly suggests the need
for more detailed studies which explore the connection between sleep
abnormalities and pain.
FIBROMYALGIA AND MYOFASCIAL PAIN SYNDROME
Although there are a number of similarities between fibromyalgia

pain syndrome and another musculoskeletal condition known as
myofascial pain syndrome, significant differences exist between
these two syndromes. Such differences need to be fully recognized
and defined, since despite their similarities these are two very distinct
conditions. For this reason, these clinical entities will be briefly jux-
taposed in this section.
Travell and Simons (1983) provided a set of criteria in order to
make a clear distinction between fibromyalgia and myofascial pain
syndrome (MPS). For example, myofascial pain syndrome is almost
always related to a trauma or strain, whereas the onset of a large num-
ber of reported cases of fibromyalgia are due to unknown factors with
only a small percentage (15 to 20 percent) attributed to physical
trauma. Patients suffering from fibromyalgia have definable indica-
tions of a sleep disorder, which is not the case with myofascial pain—
sleep disorder is only reported in a small percentage of this latter
group.
In terms of the sensation of pain, myofascial syndrome is recog-
nized by localized pain with few specific trigger points in specific
muscles. This is not the case with fibromyalgia. The pain is almost al-
ways diffuse and a large number of tender points are present. Here it
is important to make a distinction between tender and trigger points.
According to Danish (1997) a trigger point is a taut irritable band of
tissue typically located in a muscle. When aggravated by pressure,
overstretching, or activity, the trigger point refers pain to a distant
area in a characteristic pattern. Trigger points develop in response to
trauma and overuse and occur in individual muscles or regional areas
and are not a systematic phenomenon. On the other hand, a tender
point characteristic of fibromyalgia is just that: a tender or sensitive
point. A point is established as “tender” if pressure equal or less than
4 kilograms is sufficient to cause a pain response in the patient. It is
important to keep in mind that tender points do not refer pain and are
found throughout the body of a person with FM.
Finally, in terms of prognosis and treatment, there are more posi-
tive signs that myofascial pain syndrome need not become a chronic
condition. This self-limiting condition may be treated successfully
via the use of ischemic compression techniques, trigger point injec-
tion, myofascial release therapies, and spray and stretch techniques
(Travell, 1952). With regard to fibromyalgia, the data so far suggest
that the condition usually becomes chronic and its treatment requires
far more complex interventions, usually requiring medication (anal-
gesics, antidepressants, muscle relaxants, etc.) as well as specific
forms of exercise, and stress management techniques for pain man-
agement.
PHYSICAL CRITERIA
FOR THE DIAGNOSIS OF FIBROMYALGIA
The American College of Rheumatology has suggested specific

physical criteria which must be met before the diagnosis of fibro-
myalgia pain syndrome is made. These criteria include a history of
widespread pain, including bilateral pain above and below the waist.
In addition, pain in the cervical spine, the anterior chest, the thoracic
spine, or the lower back must be present (Wolfe, Smythe, and Yunus,
1990).
Another important criterion is the presence of eleven out of eighteen

tender points on digital palpation, with palpation of less than 4 kilo-
grams of force. After such a force is applied, the subject must identify
the point as “painful” and not “tender or sensitive” (Wolfe, Smythe,
and Yunus, 1990) (See Table 1.1). The presence of these specific ten-
der points constitutes one of the central criteria for the diagnosis of
fibromyalgia.
TABLE 1.1. Criteria for the diagnosis of fibromyalgia, established by the Ameri-
can College of Rheumatology
1. History of widespread pain
Definition: Pain is considered widespread when all of the following are present:
pain in the left side of the body; pain in the right side of the body; pain above the
waist; pain below the waist. In addition, axial skeletal pain (cervical spine, anterior
chest, thoracic spine, or low back pain) must be present. In this definition, shoulder
and buttock pain is considered as pain for each involved side. Low-back pain is
considered lower segment pain.
2. Pain in 11 of 18 tender points on digital palpation
Definition: Pain on digital palpation must be present in at least 11 of the following

18 tender point sites:
Occiput: bilateral, at the suboccipital muscle insertion.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at
C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the media bor-
der.
Second rib: bilateral, at the second costochondral junctions, just lateral to the junc-
tions on the upper surfaces.
Lateral epicondyle: bilateral, 2-cm distal to epicondyle.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.
Source: Wolfe, Smythe, and Yunus (1990). Reprinted by permission.

TREATMENT INTERVENTIONS
Pharmacological Interventions
The pharmacological treatment of fibromyalgia has thus far in-

cluded tricyclics such as amitriptyline, selective serotonin reuptake
inhibitors (SSRIs) such as Prozac and Paxil, and nonsteroidal anti-
inflammatory agents (NSAIDS) such as Naprosyn, ibuprofen, etc.
Russell et al. (1991), in a double-blind study found the combination
of alprazolam (an antianxiety agent) and ibuprofen to result in a sig-
nificant decrease in subjective levels of pain and objective assess-
ment of trigger points as compared to a placebo group. Such findings,
however, have been the subject of much debate and scrutiny in recent
years. Although many anti-anxiety agents may promote a relaxed
state, they should not be used for extended periods of time because
they tend to interfere with entry into deeper stages of sleep. Because of
difficulties with sleep quality and sleep maintenance in FM patients,
the use of such medications should be minimized. Some patients with
disturbing and persistent symptoms of “restless legs” have reported
some relief from these nocturnal symptoms when they were pre-
scribed low doses of klonopin. Again, long-term use of this medica-
tion is not recommended nor warranted.
Goldenberg (1986) did not find NSAIDs to be particularly helpful
by themselves in the treatment of fibromyalgia, although they are
used quite frequently in clinical practice. The use of narcotic agents is
highly discouraged due to their addictive qualities, especially be-
cause of the chronic nature of fibromyalgia. McIlwain and Bruce
(1996) also cautioned against the long-term use of NSAIDs and again
questioned their appropriateness in treating symptoms of fibromy-
algia. They listed nearly forty side effects of these medications, espe-
cially when used for an extended time. These side effects include
gastrointestinal irritation (which may become severe at times, such as
peptic ulcers and intestinal bleeding), liver and kidney damage, dizzi-
ness and disorientation, dermatological disorders, tinnitus, fatigue,
and other symptoms.
As it was indicated, antidepressants have been used rather consis-
tently in the treatment of fibromyalgia. Tricyclics (such as amitriptyline),
heterocyclics (such as trazodone), and SSRIs (such as paroxetine) have
been helpful in the treatment of this condition for perhaps two reasons.
First, they tend to increase the availability of serotonin in the brain,
which by itself has analgesic properties. Second, antidepressants have
been shown to reduce rapid eye movement (REM) sleep which may in-
directly improve the potential for an increase in Stage 4 or delta
sleep—a stage of sleep which appears to be deficient in FM patients.
These antidepressants are used at significantly lower doses in the treat-
ment of fibromyalgia and chronic pain than when they are prescribed
for the treatment of depressive disorders, such as major depression,
and dysthymia.
To date, amitriptyline appears to be one of the drugs of choice in
the treatment of fibromyalgia (McCain and Scudds, 1988). Carette
and colleagues (1986), in a double-blind, placebo-controlled study,
found amitriptyline to result in significant changes associated with
improvements in morning stiffness, sleep quality, and subjective lev-
els of pain. Elsewhere, Treadwell (1981) found amitriptyline to be
beneficial in improving tenderness in soft tissue and quality or restful
sleep. In a more recent meta-analytic study of the effects of antide-
pressants in the treatment of fibromyalgia, it was found that tricyclic
antidepressants resulted in clinically significant changes in sleep
quality, overall bodily aches, and tenderness in fibromyalgia patients
(Arnold, Keck, and Welge, 2000). The authors also suggested that
based on their findings, patients with a history of depression, anxiety,
and fibromyalgia seemed to especially benefit from therapeutic doses
of tricyclic agents. In addition to effective dosing, one must also con-
sider sufficient period of treatment for achieving desired therapeutic
effects. Currently, several research centers are exploring the thera-
peutic effects of SSRI agents in the treatment of fibromyalgia.
BIOFEEDBACK, RELAXATION THERAPY,

AND HYPNOSIS
Stress management strategies such as biofeedback and relaxation

techniques have been widely used in the treatment of chronic pain
and stress-related disorders (Gallagher, 1997). These modalities may
be of special value in the treatment of fibromyalgia. Ferraccioli,
Ghirelli, and Scita (1987) found significant improvements in fifteen
fibromyalgia patients after fifteen sessions of electromyographic

(EMG) biofeedback. The subjects showed improvements in pain rat-
ings, morning stiffness, and in tender point counts. These same sub-
jects had previously responded poorly to NSAIDs. The second part of
the study evaluated the effects of pseudo-EMG biofeedback versus
true biofeedback. Subjects in the true biofeedback group showed sig-
nificant improvements whereas the pseudo-biofeedback subjects ex-
perienced little or no change. Sadigh (1997) reported two successful
single-subject case studies in which fibromyalgia patients were pro-
vided with twelve sessions of autogenic biofeedback. Significant
changes were noted regarding patients’ subjective levels of pain, de-
pression, and somatization as measured by the Symptom Checklist,
90 Revised (SCL-90-R) (Derogotis, 1983). A six-month follow-up
showed both subjects had maintained their improvements. The obvi-
ous limitation of the study is the small sample size, and consequently
a lack of generalizability.
Another promising treatment modality has been hypnotherapy. A
study investigating the effects of hypnotherapy and physical therapy
found the former treatment to be more effective in treating symptoms
of fibromyalgia such as insomnia, subjective levels of pain, and fa-
tigue when compared with the physical therapy group. Subjects were
able to maintain their improvements in a three-month follow-up
(Haanen, Hoenderdos, and Van Romunde, 1991). More well-con-
trolled studies need to investigate the therapeutic effects of hypno-
therapy in the treatment of this syndrome.
In a recent study, Banks and colleagues (1998) explored the use of
autogenic relaxation training in affecting muscle activity, especially
in myofascial trigger points, in fibromyalgia patients. This study was
conducted on the growing support for a connection between trigger
point activities, psychological stress, tension, etc. While specific mus-
cle groups may not show much electrical activity in FM patients, trig-
ger points often do. Hence, the researchers used needle EMG sensors
to assess trigger point activity before, during, and after the practice of
autogenic (relaxation) training. Their findings showed that autogenic
training had a significant effect in reducing the trigger point activity
in FM patients. This is a most promising study which may suggest
that a combination of this technique with other important therapeutic
interventions (for example, physical therapy) may bring about lasting
relief from very painful myofascial trigger points that may be resis-
tant to other forms of treatments.
PHYSICAL THERAPY INTERVENTIONS
A variety of physical therapy modalities have shown to bring about

some positive changes in fibromyalgia patients. These include heat,
massage, stretching exercises, ultrasound, and transcutaneous elec-
trical nerve stimulation (TENS) (Hench and Mitler, 1986). Massage
therapy is one of the oldest forms of medical interventions and is in-
creasingly being recognized (perhaps rediscovered is a better word)
for its therapeutic value. In addition to making sore muscles feel
better, when properly administered, massage can improve circula-
tion, alleviate pain, and reduce physical as well as mental tension.
When combined with other therapeutic modalities such as heat, trans-
cutaneous electrical nerve stimulation (TENS), and microcurrent electri-
cal nerve stimulation (MENS), massage therapy can prove to be of
significant benefit to fibromyalgia and chronic pain sufferers.
Whereas in the treatment of myofascial pain syndrome specific
physical therapy modalities have been shown to play an important
therapeutic role (e.g., the spray and stretch technique) and may have
lasting effects, their long-term effectiveness in the treatment of fibro-
myalgia requires further investigation (Goldenberg, 1989b). Mean-
while, manual and gentle physical therapy, because of its profound
psychophysiological implications, is likely to become a highly prom-
ising area of research. Also, there are strong suggestions that medi-
cally supervised physical exercises such as cardiovascular fitness
training do bring about desirable changes in some of the symptoms of
fibromyalgia.
Danish (1997) has developed a comprehensive physical therapy
approach to the treatment of fibromyalgia pain syndrome. This ap-
proach combines gentle, manual physical therapy (craniosacral ther-
apies, gentle massage, myofascial release), and applications of micro-
current therapies, with active stretching exercises and education. He
summarizes his approach in the acronym PACE which stands for:
Pain (modulating pain via some of the above mentioned modalities);
Activity (stretching, flexibility, and movement exercises); Condi-
tioning (aerobic, aquatic, and light resistance training); and Educa-

tion (nature of FM, lifestyle changes, etc.).
FIBROMYALGIA AND PSYCHOBIOLOGICAL

DISREGULATION
After nearly two decades of extensive research, fibromyalgia re-

mains an enigma. Currently there is a lack of a unifying theoretical
model that explains the etiology of this condition. In my recent work
(Sadigh and Mierzwa, 1995; Sadigh, 2001) I have suggested that
fibromyalgia needs to be reconceptualized as a system-wide state of
psychobiological disregulation (note: the term psychobiological dis-
regulation was coined by Schwartz, 1979). Based on the pioneering
work of Schwartz (1979, 1989), the psychobiological disregulation
formulation emphasizes the need for exploring the role of neuro-
endocrine, developmental and intrapsychic factors in the pathogenesis
of chronic disorders, such as the fibromyalgia pain syndrome. The
plethora of symptoms experienced by fibromyalgia patients suggest a
systemic phenomenon at work. Again we see evidence of disturbance
in almost every system in a large number of fibromyalgia patients.
This may indeed suggest a system-wide state of disarray.
Based on the general system theory, the disregulation model sug-
gests that ultimately all functioning systems (e.g., the human body)
are self-regulating (Schwartz, 1979; von Bertalanffy, 1968). How-
ever, if a disruption occurs in one of the subsystems, this will, in time,
result in a system-wide state of disorder and disregulation. It has been
suggested that perhaps one possible reason that a “cure” for fibro-
myalgia has remained elusive is because we have placed undue em-
phasis on the symptomology of the syndrome instead of gaining a
fuller perspective regarding its dynamics (Sadigh, 2001). First, a shift
must be made from conceptualizing this condition as mainly muscu-
loskeletal. The musculoskeletal system is a massive subsystem of the
human body and clearly tends to receive more attention, especially in
terms of symptom manifestation. However, it is only one subsystem
among many and it may reveal only partial knowledge regarding the
complete pathophysiological nature of the FM.
It is prudent to consider not only the manifestation of the musculo-

skeletal symptoms but also other subsystems, without attempting to
overemphasize a particular system at the expense of others. Once this
approach, which requires a multidisciplinary or team effort, is under-
taken, then it is quite possible that we will take a giant step toward
more fully appreciating the clinical data. The obtained data can then
be used to formulate more effective methods of pursuing the central
issues that concern the emergence of the symptoms. Such an ap-
proach is likely to reveal that at the heart of this condition resides a
profound level of system-wide state of psychobiological disregulation.
This suggests overregulation of some subsystems while at the same
time underregulation of other systems. Underregulated systems are
likely to be compensated by those other systems (overregulated)
which work overtime to maintain a state of balance for the moment,
regardless of the cost later on, at which time these compensatory sys-
tems become depleted. System-wide disarray ensues. It is the rees-
tablishment of regulatory mechanisms that will finally result in the
achievement of a state of order and a disappearance of the symptoms
of disorder.
Autogenic training, which was solely founded on the premise of re-
establishing the body’s homeostasis or state of balance, is therefore a
valid approach that may be used as one of the potential treatments for
fibromyalgia pain syndrome. When autogenic training—whose pur-
pose is to promote a greater level of balance, self-regulation, and or-
der within the body—is combined with other therapeutic approaches,
such as pharmacological, physical therapy, etc., it is quite likely that
we will begin a steady decrease in the intensity and manifestation of
fibromyalgia symptoms. In time, with the help of data generated from
ongoing research, a systematic approach for a more comprehensive
treatment of this condition may emerge.
Chapter 2
Stress and Pain
Stress increasingly has become a part of the vocabulary of the phy-

sician, the mental heath professional, and the layperson. Scientific re-
search in the field of mind-body medicine suggests that there is a
significant positive correlation between stress levels and a variety of
complicating psychological and physical symptoms (Girdano, Everly,
and Dusek, 1997). Some of these complications include fatigue, de-
pression, panic attacks, gastrointestinal symptoms, and alcoholism
(Selye, 1976). Sackheim and Weber (1982) noticed that a variety of
conditions such as chronic pain, musculoskeletal pain syndrome, and
rheumatic pain appeared to be significantly affected by chronic
stress. Stress is now also known to be a major contributor to coronary
heart disease, cancer, lung ailments, accidental injuries, and suicide
(Charlesworth and Nathan, 1984). It should come as no great surprise
that some of the best-selling medications in the United States are pre-
scribed for stress-related conditions.
The physiological, emotional, and cognitive changes that are brought
on by chronic pain are almost identical to those experienced as a re-
sult of exposure to prolonged stress. Therefore, we may conclude that
the experience of chronic pain is potentially the most damaging form
of stress. While people can, at least temporarily, get away from a
stressful job environment or a stressful relationship, chronic pain suf-
ferers cannot simply leave their pain behind even for a short while. To
effectively survive persistent pain, one needs to learn to manage it
and its concomitant stress. For this reason, a thorough knowledge of
the mechanisms of stress and the rationale for useful coping tech-
niques is in order.
25
THE CONCEPT OF STRESS
Stress is derived from the Latin “stringere” which means to strangle

or tightly bind (Jencks, 1977). Before entering the psychophysio-
logical and the medical vocabulary, the term was primarily used by en-
gineers. For example, in metallurgy, when significant force is placed
upon a piece of metal until it fractures, it is said that the metal has
reached its “stress point.” Now, the word has become commonplace
and is viewed by many as a detrimental state which can bring about a
host of psychological, emotional, and physical complications.
Research on stress is so extensive that virtually a month does not
go by without the word finding its way into the medical and the psy-
chological literature. There is, however, a lack of consensus about a
precise definition of the word. In this vein Elliot and Eisdorfer (1982)
stated that, “After thirty-five years, no one has formulated a definition
of stress that satisfies even a majority of stress researchers” (p. 11).
Sklar and Anisman (1981) defined stress as the psychophysio-
logical outcome of exposure to a demanding or harmful condition.
The initial reaction to stress is believed to bring about adaptive
changes needed to meet situational demands placed upon the person.
If these demands, such as seen in chronic medical conditions, are se-
vere, persistent, and prolonged, the coping mechanisms may not be
able to prevent the eventual tissue breakdown with life-threatening
consequences.
McLean (1979) stated that stress is the reaction to any physical,
psychological, emotional, cognitive, or behavioral sources of stimu-
lation which result in an emergency fight-or-flight response. From a
psychological standpoint, one may experience anxiety, feelings of
distress, and arousal. Physiologically, one experiences increased heart
rate, elevated blood pressure, higher electrodermal (skin) activity,
and changes in electroencephalic (brain wave) activity. Finally, on
the behavioral level one experiences trembling, stuttering, and physi-
cal avoidance of the stressor. Given the above dimensions of the
stress response, a comprehensive definition of stress must attempt to
incorporate these three dimensions.
Convincing evidence suggests that a strong positive correlation ex-
ists between stress levels and the development of degenerative ill-
nesses such as rheumatoid arthritis, hypertension, and cardiac disease.
Stress and Pain 27
Cohen (1980), in his review of the literature about the aftereffects of

stress, noted that exposure to unpredictable and uncontrollable stress,
a concomitant of chronic pain, is followed by a decrease in sensitivity
to others. This may include a decrease in helping behavior and an in-
crease in aggression toward others.
Recently, a growing interest has developed in the field of psycho-
neuroimmunology—a field which is primarily concerned with the
immune system and how it is affected by stressful psychological and
emotional events. It has been documented that any stressful process
which alters the normal physiology of the body will naturally have an
impact on the immune system. This may result in susceptibility to
colds, infections, the development of arthritis, and even various forms
of cancer (Charlesworth and Nathan, 1984). Also, Sklar and Anisman
(1981), in their study of the relationship between stress and cancer,
found that tumor growth is intensified after long exposure to uncon-
trollable stress.
MODELS OF STRESS
Currently, there exist three models of stress which represent several
dominant schools of thought in this field: the stimulus (life events)
model, the response model, and the interfactional model.
The Stimulus Model

Stress considered as stimulus has been used to describe social
and/or environmental events characterized as sudden, unexpected,
new, or rapidly changing. Lazarus (1966) included as stress stimuli
such events as threat of failure, isolation, bereavement, and rapid so-
cial change.
Stress as stimulus has resulted in much research in the area of life
events and their impact on physical and psychological health. Based
on this model, Holmes and Rahe (1967) developed the Social Re-
adjustment Rating Scale (SRRS) to determine the relationship between
life changes, the onset of illness, and its severity. They discovered a
strong positive correlation between major health changes and life crises,
such as death of a spouse, divorce, marital separation, and death of a
close family member. Furthermore, they demonstrated that even cer-
tain positive events could be viewed as a cause of stress with potential

health-threatening effects. In other words, any event in the life of a per-
son that requires him or her to make certain adjustments is considered a
source of stress. Too many adjustments in too short a time is cause for
concern about the person’s physical and psychological well-being.
For many years, the SRRS became one of the most popular instru-
ments for measuring stress. Many investigators used the Holmes and
Rahe scale in their exploration of the impact of life events on the
health and well-being of people in different walks of life. A few years
ago, some insurance companies used the SRRS to help people better
plan for appropriate insurance coverage. Table 2.1 is the instrument
in its entirety as it appeared in the Journal of Psychosomatic Re-
search in 1967. As one may note, some of the items are clearly dated
as compared to the way of life in the 1960s (most mortgages today are
ten times more than the example in the table).
Based on the initial studies, the interpretation of the results of the
instrument are quite straightforward. Those individuals with scores
between 200 to 300 have a 50 percent likelihood of developing a seri-
ous condition which would require medical intervention. On the
other hand, those with scores of 300 and above have an 80 percent
likelihood of suffering from a serious medical illness within the sub-
sequent twelve months. The chances of developing clinical depres-
sion also rise with scores above 300. Although the instrument was not
as accurate as it was hoped to be, it clearly showed that the experience
of certain social and environmental sources of stress contributes to
the development of medical conditions.
In recent years, there has been abundant criticism of the stimulus
model of stress. Several researchers have argued that this model does
not consider other important variables such as coping resources, antici-
patory reactions, and individual differences (Lazarus and Folkman, 1984).
Furthermore, others have stated that the SRRS, which was constructed
based on the stimulus model, is not an appropriate instrument for all
populations such as chronic pain patients. For example, the instrument
does not reflect stressors such as powerlessness, helplessness, and
hopelessness. Other special issues that chronic pain patients experi-
ence that are not reflected in the SRRS are constant physical discom-
fort, adjustments to pain, making career decisions, and difficulties with
achieving quality sleep.
Stress and Pain 29
TABLE 2.1. The Social Readjustment Rating Scale
Life Events Point Value

Death of a spouse 100
Divorce 73
Marital separation 65
Jail term 63
Death of a close family member 63
Personal injury or illness 53
Marriage 50
Fired at work 47
Marital reconciliation 45
Retirement 45
Changes in health of family member 44
Pregnancy 40
Sex difficulties 39
Gain of new family member 39
Business readjustment 39
Changes in financial state 38
Death of close friend 37
Change to different line of work 36
Change in number of arguments with spouse 35
Mortgage or loan over $10,000 31
Foreclosure of mortgage or loan 30
Changes in responsibilities at work 29
Son or daughter leaving home 29
Trouble with in-laws 29
Outstanding personal achievement 28
Spouse begin or stop work 26
Begin or stop work 26
Change in living conditions 25
Revision of personal habits 24
Trouble with boss 23
Changes in work hours or conditions 20
Changes in residence 20
Change in schools 20
Change in recreation 19
Changes in church activities 19
Changes in social activities 18
Mortgage or loan less than $10,000 17
Changes in sleeping habits 16
Changes in the number of family get-togethers 15
Changes in eating habits 15
Vacation 13
Christmas 12
Minor violations of the law 11
Total Score ____
Source: Holmes and Rahe (1967). Reprinted by permission.

The Response Model
One of the most detailed and popular models of stress is the re-
sponse model, which was proposed by Hans Selye (1950), perhaps
the most respected pioneer in stress research. According to Selye
(1984), stress is a generalized bodily response to a demand that is
placed upon the body. That is, when the homeostasis of the body is
disturbed, certain internal processes begin to take place as a form of
preparation for dealing with the disruption. This loss of a state of bal-
ance, if prolonged, can result in the development of certain illnesses
and even death.
After studying pathological changes in sick humans and over-
stressed animals, Selye (1950) proposed the existence of a stress syn-
drome made up of the physiological changes that spontaneously oc-
cur and stimulate the body’s defensive reactions in response to any
stressor, physical or psychological. The syndrome is known as gen-
eral adaptation syndrome or GAS, and consists of three stages. The
first stage of GAS is termed the alarm reaction. This reaction consists
of activation of the body’s defenses to combat the stressor and in turn
secretes biochemicals which bring about an increase in heart rate,
higher oxygen consumption, and a drastic increase in the metabolic
activity. This powerful activation of the body’s energy resources can
only be maintained for a short time.
Eventually the body adjusts to the stressor and the second stage of
GAS, called adaptation, ensues. During this stage, levels of resis-
tance and coping rise above normal. However, the adaptive energy of
the body is finite and after prolonged exposure to the stressor, the
body becomes depleted of its resources.
This depletion results in exhaustion, which is the third stage of
GAS. During this stage, the body’s resistance is diminished and symp-
toms of varying intensity are experienced. If the stressor is severe
enough, irreparable damage may occur to the body. Although the body
normally resists and adapts to various stressors, its coping mechanism
can become derailed, and the individual may suffer from the harmful
and even life-threatening effects of stress. Too much of this undue
stress or distress (also known as “bad” stress) may result in what Selye
called the disease of adaptation or stress diseases (Selye, 1982). A list
of distress symptoms include (Selye, 1976, pp. 174-177):
Stress and Pain 31
1. General irritability
2. Pounding of the heart
3. Dryness of the throat and mouth
4. Impulsive behavior
5. Inability to concentrate
6. Weakness or dizziness
7. Floating anxiety
8. Insomnia
9. Loss of or excessive appetite
10. Queasiness of the stomach
11. Alcohol and drug addiction
12. Neurotic behavior
13. Psychosis
The response model of stress as proposed by Selye has also been

criticized in recent years. A major criticism came from the formula-
tion that the stress reaction is a uniform process. This notion has been
effectively challenged by studies that have explored the role of per-
ception in the stress response. That is, two people may have signifi-
cantly different responses to an identical stressor depending on their
perceptions of the stressor. This has necessitated the development of
other models such as the one proposed by Lazarus.
The Interfactional Model
Lazarus (1966) and Lazarus and Folkman (1984) proposed an

interfactional or transactional model of stress. This model, which is
growing in popularity, suggested that it is the combination, or interac-
tion of situations, and inherited tendencies that control the person’s
reaction to stressful situations. This model places greater emphasis on
individual differences, both in terms of physical and emotional makeup.
This suggests that an individual’s stress responses cannot be easily
anticipated, nor is it accurate to make conclusions about the person’s
response to stress simply by assessing environmental and/or life
events.
When either the internal or environmental demands (or both) of a
person exceed his or her resources for coping, the person begins to
experience the adverse effects of stress. As noted, some people may
be exposed to an identical source of stress and may respond quite dif-

ferently. As we will discuss later, some may respond with little agita-
tion when they begin to experience another “bad pain day,” while
another person may feel quite overwhelmed.
Based on this model, stress is defined as any event in which envi-
ronmental, internal demands, or both, surpass the adaptive resources
of the person. In this view, stress involves a transaction, a give and
take, in which the availability of resources must be determined before
expending them. Another way of looking at this model is to say that
the person assesses or appraises the nature of the demand and avail-
able resources for coping with it, and then engages in a response
(Lazarus and Folkman, 1984). How an individual responds to stress-
ful experiences, therefore, is a function of both personal factors and
the situation (Lazarus et al.,1985).
After reflecting on the description of this model, it is important to
educate patients that just because others can handle certain stressful
situations, it does not mean that they should be able to do the same. If
the patient’s resources are depleted or are near depletion, a “simple”
task such as getting dressed and going to the corner store may seem
so enormous that the mere thought of it may make him or her feel
tired. There are days when many chronic pain patients find it difficult
even to get out of bed. Unfortunately, most of them continue to fur-
ther deplete their energies by becoming upset or giving up all to-
gether and spending hours in bed, which is likely to further result in
stiffness and additional pain.
PSYCHOPHYSIOLOGY OF STRESS
During the last few decades, much knowledge has been gained
with regard to the biochemistry and the psychophysiology of stress.
The two systems that are primarily responsible for the stress response
are the sympathetic-adrenal medullary system (SAM) and the hypo-
thalamic-pituitary-adrenocortical system (HPAC) (Girdano, Everly,
and Dusek, 1997). Because of their central role in understanding the
stress phenomenon and how pain can bring about significant bio-
chemical changes, these two systems and their functions will be
briefly discussed in this section.
Stress and Pain 33
The Sympathetic-Adrenal Medullary System (SAM)
The autonomic nervous system (ANS) is that branch of the periph-

eral nervous system that is responsible for regulating the functions of
all the visceral systems in the body (e.g., the cardiovascular system,
the respiratory system, the gastrointestinal system, and the excretory
system), as well as the smooth muscles. The ANS operates beyond
conscious awareness and as a result was referred to as the involuntary
nervous system in years past. With the advent of applied psycho-
physiology, namely biofeedback, it is possible to gain some con-
scious control over the activity of this branch of the nervous system.
The ANS is composed of two subsystems, the sympathetic ner-
vous system (SNS) and the parasympathetic nervous system (PNS).
Whereas the SNS is generally responsible for increasing the activities
of various organs, such as increasing the heart rate and constricting
blood vessels (for the most part), the PNS reduces their activities,
such as lowering the respiratory rate, decreasing the heart rate, stimu-
lating digestion, and allowing bodily repair to take place.
The sympathetic nervous system has a catabolic function, that is
utilizing resources to increase energy expenditure. On the other hand,
the function of the parasympathetic nervous system is to reduce en-
ergy expenditure and to replenish the bodily resources. The sympa-
thetic nervous system is activated during a stress response, such as
when a certain source of threat is perceived, and the parasympathetic
nervous system is activated during the regeneration response.
The scientific interest in the impact of the sympathetic activation
in stressful situations may be traced back to the observations of the
prominent physiologist Walter B. Cannon (1932), who introduced the
concept of the fight-or-flight response. Since Cannon’s early studies of
the fight-or-flight response, a large body of evidence has suggested that
the sympathetic activity plays a major role in the stress response. The
sympathetic-adrenal medulla (SAM) axis of the stress response func-
tions in the following fashion. When a person encounters a threaten-
ing and/or stressful situation, the SNS stimulates the adrenal medulla,
the inner layer of the adrenal glands which are located on top of the
kidneys, and hormones such as adrenaline and noradrenaline are se-
creted (Hassett, 1978). These hormones are collectively referred to as
catecholamines.
It has been documented that overactivation of the sympathetic-

adreno-medullary system may result in a chain of reactions that could
eventually result in physical and psychological complications. For
example, excessive catecholamine secretion is believed to cause
many of the illnesses associated with stress such as hypertension, in-
creased cardiac output, disorders of the digestive tract such as indi-
gestion and irritable bowel syndrome, constriction of peripheral
(arms, hands, legs, and feet) blood vessels, and dilation of blood ves-
sels within the internal organs (Selye, 1984). The constriction of pe-
ripheral blood vessels has also been implicated in conditions such as
Raynaud’s disease, in which sufferers experience extremely cold
hands and feet even to the point that their hands actually turn blue.
This extremely painful condition is especially aggravated by pro-
longed exposure to stress. Many fibromyalgia patients often complain
of similar symptoms, although they may not meet the specific criteria
for the diagnosis of Raynaud’s disease.
Prolonged activation of the sympathetic adreno-medullary system
due to stress and pain may also result in a condition known as
dysautonomia which results in fluctuations and even at times an
abrupt drop in blood pressure. Sudden dizziness and fatigue are some
of the most common symptoms of this condition. Problems with de-
pression and sleep disorders may also be attributed to states of dys-
function and depletion in this system. That is why certain antidepres-
sants (for example, Effexor) are used to help some of the symptoms of
chronic pain because they help to replenish and make more available
the needed levels of noradrenaline in the brain.
The Hypothalamic Pituitary-Adrenocortical System (HPAC)
Another system which plays an important role in the stress re-

sponse is the hypothalamic pituitary-adrenocortical system (HPAC).
This system begins with the hypothalamus, a major regulatory mech-
anism in the brain which closely interacts with the master hormonal
regulator, the pituitary gland, located at the base of the brain. The hy-
pothalamus interacts with the pituitary gland via the production of
the corticotropin releasing factor (CRF). Once a stressful stimulus
(e.g., physical, psychological, environmental) is perceived and CRF
is released, the pituitary gland stimulates the outer layer of the adre-
Stress and Pain 35
nal gland (the adrenal cortex) through the secretion of the adreno-
corticotrophic hormone (ACTH). As a result of the stimulation of the
adrenal cortex, specialized hormones known as glucocorticoids (such
as cortisol and corticosterone) are poured into the bloodstream.
Cortisol is primarily involved in the metabolic function through the
process of gluconeogenesis, which provides the body with the needed
source of energy. Cortisol also plays an important role in reducing in-
flammation and inhibiting fluid loss. Prolonged secretion of cortisol
may result in structural damage (tissue degeneration), muscle wast-
ing, and suppression of the body’s immune system (Selye, 1982).
Some studies have shown that the secretion of cortisol appeared to be
especially high among people who were struggling with emotional
stress and felt ineffective in managing their situation (Schneiderman
and Tapp, 1985).
A depletion of cortisol may result in adrenal insufficiency. Symp-
toms include fatigue, weakness, diabetic-like symptoms, and im-
mune dysfunction. Indeed, one of the most common symptoms of
cortisol insufficiency is debilitating fatigue, followed by joint pain,
muscle pain, swollen glands, allergic responses, and finally distur-
bances in mood and sleep (Baxter and Tyrell, 1981). Griep, Boersma,
and de Kloet (1993), in their study of patients with primary fibro-
myalgia, concluded that these patients suffered from adrenal insuffi-
ciency which may be due to exposure to prolonged stress. The
authors also suggested that the reduced cortisol levels may explain
changes in aerobic capacity and the consequent impairment in mus-
cle activity.
The other hormone produced by the adrenal cortex is aldosterone.
Aldosterone affects the availability of certain minerals which are cru-
cial for proper heart and muscle functioning. This mineralocorticoid
is responsible for intercellular retention of calcium, sodium, and wa-
ter, as well as the excretion of intercellular potassium and magne-
sium. It is important to note that many fibromyalgia and chronic
fatigue patients are found to be deficient in magnesium, which plays
an important role in metabolic functions (Cox, Campbell, and Dowson,
1991; Eisinger et al., 1994). In chronic exposure to stress, the reten-
tion of additional sodium may result in edema, bloating, and signifi-
cant changes in the blood pressure.
A number of studies have suggested that during the experience of

constant, unabating stress, such as in chronic conditions, the activi-
ties of the adrenals can become chaotic and quite problematic. For
example, a person’s neurochemical system may begin to respond in a
haphazard, unnecessary fashion to a minor stressor that may be quite
harmless but is perceived as threatening. Again, such inappropriate
stress responses are especially seen in those who feel helpless and
“victims” of a chronic condition. An increase in a sense of mastery
over the situation appears to gradually rectify this problem.
In summary, both the SAM and the HPAC axes play important
functions in the stress response. Prolonged activation of the two sys-
tems appears to be responsible for potentially deleterious effects that
can even become life threatening (Cohen et al., 1986). Chronic condi-
tions, such as chronic pain, if not managed properly can in time bring
about a breakdown in various body systems. I can easily recall at least
a dozen chronic pain patients who reported that they always had low
blood pressure only to realize that after a few years of grappling with
pain, “all of a sudden,” they were diagnosed with hypertension. There
are also those who “suddenly” discover that they have diabetes or a
bleeding ulcer.
Again, it is important to note that it is not pain that causes these
conditions, but prolonged stress in addition to some hereditary vul-
nerability. Since stress inevitably tends to increase the body’s rate of
wear and tear, dormant conditions that are often genetically linked
can become visible in time—often surprising the person by the sud-
den appearance of unexpected symptoms.
Therefore, stress reduction and management play important roles
in treating patients who are suffering from chronic pain and other
chronic conditions. In the next chapter we will review several tech-
niques that purport to accomplish this task. Once patients have an ad-
equate knowledge of such approaches, they can then begin incorporat-
ing them into their daily activities.
Chapter 3
Methods of Stress Management
In recent years, concern over the stress epidemic has promoted

much research and investigations in the areas of stress management
and stress reduction. Several stress management interventions that
have been advocated by different practitioners and researchers in-
clude relaxation training, psychotherapy, assertiveness training, bio-
feedback, and cognitive restructuring. Among these, relaxation strate-
gies have shown strong empirical support for their ability to result in
physical, psychological, and emotional improvements. It has been
suggested that some of the most effective and nonintrusive methods
of managing pain and stress are relaxation therapies and psycho-
physiological methods such as biofeedback (Gallagher, 1997). Stoyva
and Anderson (1982) suggest that the major reason relaxation tech-
niques have shown superiority over other stress reduction procedures
is because they bring about psychophysiological changes which are
diametrically opposed to the active/striving (stressed) mode.
Well-designed studies that have incorporated cognitive and behav-
ioral techniques for pain and stress management have been shown to
be superior to routine medical interventions (Keefe and Van Horn,
1993). These relatively inexpensive procedures tend to cause physi-
cal and psychological improvements that have a lasting effect. When
combined with other treatments, these interventions can be very ben-
eficial to those who are grappling with persistent and unremitting
pain (Berman, 1997).
STRESS MANAGEMENT TECHNIQUES
The widespread prevalence and harmful effects of stress have re-

sulted in the development of a variety of stress-management tech-
37
niques and strategies. The most widely used stress-management

techniques are cognitive restructuring, biofeedback, stress inocula-
tion, and relaxation training. These techniques and approaches will
be discussed briefly in this section.
Cognitive Restructuring
People often are not aware that there is an intimate interaction be-
tween our thoughts, feelings, and behaviors. A negative thought can
almost instantly have emotional manifestations, which may in turn
influence the way one behaves. This is especially important to keep in
mind when we are experiencing persistent pain. At times a simple
twinge of pain may result in anxiety, fear, frustration, and even help-
lessness. This may result in behavior that may actually worsen the
pain. The behavior will cause more negative thoughts and feelings,
which makes one feel trapped in a vicious cycle with no end in sight.
The major task of cognitive restructuring is to assist people to be-
come aware of their faulty thoughts (cognition) and to teach them
ways of modifying or replacing these thoughts with more construc-
tive ones, which will bring about a change in feelings and behaviors.
In a clinical setting, and with the help of a trained therapist, this is ac-
complished through exploratory interviews, visualization techniques,
and self-monitoring homework (Beck, 1984). After exploring the na-
ture of the faulty thinking (for example, “This is going to be a terrible
day because I woke up with pain”), the individual is provided with
specific techniques and homework assignments to develop a new
cognitive repertoire (more positive and helpful thoughts) with which
to counteract stress-provoking thoughts, feelings and behaviors (Beck,
1976). During a cognitive-restructuring session, the therapist may
ask the patient to think of different stressful situations when negative
thoughts may arise. Such thoughts are then replaced with more realis-
tic or positive ones, for example, “Just because I woke up with pain it
does not mean that my day is ruined. Perhaps instead of staying in
bed I should take a hot bath which has helped me in the past.”
According to Beck (1984), it is the cognitive structuring of a situa-
tion (the way one thinks or views the situation) that contributes to a
stress response. Therefore, cognitive restructuring (or revising) low-
ers physiological arousal and counteracts the deleterious effects of
Methods of Stress Management 39
stress. Cognitive restructuring has proved effective in reducing spe-

cific stress reactions due to chronic pain and other chronic conditions
(Turk, Meichenbaum, and Genest, 1983). This approach has also
been used successfully and effectively in reducing stress connected
with coping with physical anxiety and anger (Meichenbaum, 1977).
Many researchers have found cognitive restructuring and a modified
form of systematic desensitization to be equally effective in treating
chronic stress.
Biofeedback
Biofeedback is the use of instrumentation (often electronic) to pro-

vide psychophysiological (mind-body) information about activities
and processes that the person is not normally aware of and which may
be brought under conscious control, such as learning to increase
one’s circulation in the hands and the feet. To achieve this, the person
is provided with immediate and continuous information about his or
her biological conditions, such as muscular tension, peripheral tem-
perature, and blood pressure. This “returned” information or feed-
back helps the person become an active participant in reducing
tension, managing stress, and enhancing his or her health mainte-
nance (Fuller, 1986).
According to Stoyva and Anderson (1982), biofeedback instru-
mentation helps patients become aware that they are developing an
effective stress-reducing response. Some individuals who have diffi-
culty relaxing may, in a short while, learn to reduce tension through
the use of biofeedback techniques. There is no longer a need to guess
what works or if a technique is having an effect. With biofeedback in-
struments such knowledge is made available quite readily and effec-
tively.
The most common biofeedback technique that has shown to be
highly effective in counteracting the harmful effects of stress is
electromyographic feedback (EMG), which provides individuals with
immediate information about their muscular tension. Muscular relax-
ation has long been noted as an important treatment factor for a vari-
ety of psychophysiological and stress-related disorders (Olton and
Noonberg, 1980).
Budzynski and colleagues (1973) found EMG to be more effective

in obtaining a state of muscular relaxation than progressive relax-
ation. Tarler-Benlolo (1978) suggests that a combination of biofeed-
back and relaxation therapy should prove to be a more powerful
stress-management strategy than either technique used alone. (Bio-
feedback will be discussed in more detail in Chapter 15.)
Stress Inoculation
Stress inoculation training may be viewed as a form of cognitive

restructuring and is a systematic program of providing coping re-
sponses to more effectively cope with a wide range of stressful situa-
tions including chronic pain and headaches (Meichenbaum, 1985).
Stress inoculation has been referred to as a form of “psychological
vaccination” that helps the individual more effectively handle diffi-
cult situations. In other words, it provides the individual with “. . . a
prospective defense or set of skills to deal with future stressful situa-
tions. As in medical inoculation, a person’s resistance is enhanced by
exposure to a stimulus strong enough to arouse defenses without be-
ing so powerful that it overcome them” (Meichenbaum and Turk,
1976, p. 3). This approach provides coping strategies that can be used
with sources of stress on the cognitive, physiological, and behavioral
levels.
Meichenbaum (1985) proposed a three-step process that was de-
veloped to prevent or reduce stress and to result in behavior change.
These are: education, rehearsal, and application.
Education
The first stage of stress inoculation is based on information gather-

ing and is essentially instructional in nature. The therapist and the
patient briefly discuss the nature and sources of stress, such as pain,
anxiety or anger. Special attention is placed upon the patient’s think-
ing patterns when he or she experiences a source of stress. Further-
more, patients are asked to discuss coping strategies that they are
currently using.
After gathering this information, the therapist will provide the pa-
tient with an examination of his or her emotional responses based on
certain thoughts and how a stressor brings on such responses. It is be-

lieved that as a result of the information gathering educational phase,
the patient becomes aware of his or her maladaptive thoughts and be-
haviors. Such awareness will allow him or her to pay particular atten-
tion to thoughts, feelings, and behaviors that need to be changed
(Meichenbaum, 1977).
Rehearsal
The second step of stress inoculation is rehearsal. During this step,

patients are provided with specific coping techniques to change their
thoughts and behaviors. For example, relaxation techniques may be
taught to reduce physiological reactivity to stressful situations. Be-
havioral skills may also be taught to enlarge one’s repertoire of re-
sponses. The main focus of this phase of treatment is to provide
appropriate and more effective coping skills that can be used with
greater flexibility. Furthermore, the training involves mastery of an
assortment of techniques that can be used to combat the negative ef-
fects of stress. Special attention is paid to the development of a col-
lection of positively phrased coping self-statements. This allows the
individual to more rationally estimate a stressful or threatening situa-
tion and utilize appropriate coping skills.
Application
During the final step of stress inoculation, the application stage,

the therapist helps the patient to apply the techniques and the skills
that have been taught into proactive, daily use. The individual may be
asked to imagine or visualize certain situations and to put to use some
of the acquired techniques (in vitro training). From mental images,
one then moves to applying these skills in real situations (in vivo
training). As coping skills are rehearsed and a greater sense of self-
mastery is achieved, the patient begins to move away from a preoccu-
pation with avoiding stress and demands and is likely to begin consid-
ering more positive and constructive options. From time to time, it
may be necessary to review one’s repertoire of skills and if necessary
add new responses to them. Also, “booster” sessions are often recom-
mended to help avoid setbacks.
Relaxation Training
Relaxation techniques are widely used strategies to manage and

reduce pain and stress. It is believed that practices similar to relax-
ation methods have been used in medical treatment of a variety of
conditions in some cultures for thousands of years. Some have esti-
mated that over 5,000 years ago, the Egyptian priests frequently
treated disease through various forms of imagery relaxation (Lavey
and Taylor, 1985).
In recent years, the growing concern over the deleterious effects of
exposure to prolonged and uncontrollable stress has prompted scien-
tists and clinicians to explore the effectiveness of a variety of stress
reduction techniques and interventions. Among various stress man-
agement approaches, relaxation procedures have provided strong
empirical support for bringing about positive physiological, psycho-
logical, and emotional changes.
It has been shown that relaxation may provide three therapeutic
gains: a balancing and reconditioning of the central nervous system;
desensitization of distressing thoughts; and insight into ongoing,
damaging and ineffectual patterns of behavior. Regular practice of re-
laxation techniques has proven to be of considerable psychological
and emotional value in dealing with stressful situations—a value that
is difficult to ignore when the overall safety and cost-effectiveness of
this training is considered.
Stoyva and Anderson (1982) conducted a study in which patients
who were suffering from stress-linked disorders were closely watched
and many of their psychophysiological activities monitored. They
found that these patients showed signs of high autonomic arousal
even when they were not placed in stressful situations. Hence, it was
concluded that such people lacked the ability to shift to a rest condi-
tion—a condition that can be helped by various relaxation tech-
niques.
Relaxation therapy was introduced into the modern Western world
by Johannes Schultz in Germany (autogenic training), and Edmund Ja-
cobson in the United States (progressive relaxation). Pelletier (1979)
stated that almost all meditative-relaxation techniques result in a de-
crease in sympathetic activity and an increase in parasympathetic ac-
tivity. The increase in parasympathetic activity results in cellular
repair as well as decreased blood pressure, lower respiratory rate, and

relaxation of the skeletal muscle. Perhaps that is why relaxation ap-
proaches have been shown to counteract the harmful and damaging
effects of stress and result in improved health.
Carson and colleagues (1988) examined the effect of meditative-
relaxation on systolic blood pressure, plasma lipids, and blood glu-
cose of a group of highly stressed patients. Subjects were assigned to
either a placebo/control group or relaxation treatment group. Sub-
jects’ blood pressure and cholesterol levels were closely monitored
throughout treatment. After an eight-week period of treatment, those
subjects who practiced relaxation showed a significant decrease in
their systolic blood pressure, and a significant reduction in plasma
lipids and cholesterol. The placebo-control group remained unchanged.
The authors suggested that evidence supports that relaxation can be
used as a strong preventative modality in reducing cardiac disease.
Also, a large number of well-controlled studies have clearly docu-
mented that relaxation exercises can be effectively used to reduce
pain, reduce the use of pain medications, and finally reduce the fre-
quency of visits to the emergency room (Schwartz, 1984). A study by
Turner (1982), showed that patients who practiced muscle relaxation
techniques were able to significantly reduce their need for medica-
tion and felt less depressed when compared to those patients who did
not receive relaxation training. What is important to note is that after
a two-year follow-up, the relaxation group was still showing signs of
improvement.
Even when pain is chronic and extremely severe, relaxation tech-
niques seem to make a substantial difference in improving patients’
coping abilities. A study by Grzesiak (1977) employed relaxation
training in assisting patients who were suffering from persistent pain
due to spinal cord lesions. In addition to relaxation training, the pa-
tients were taught to use peaceful imagery to enhance pain manage-
ment. All the patients reported a reduction in pain and an improvement
in their overall mood.
Relaxation techniques that have been supported empirically in-
clude: autogenic training, breathing exercises, imagery techniques,
transcendental meditation, progressive relaxation, and yoga training.
Because of their importance and their relevance to pain management,
these techniques will be briefly discussed in this section.
Autogenic Training
A clinically well-recognized technique for improving stress and

pain management is autogenic training (Schultz and Luthe, 1959).
The term autogenic is derived from the Latin, autos (from within),
and genos (generated and developed) (Jencks,1979). That is to say,
autogenic training helps to bring about changes that are generated
from within. The main task of this training is to allow the body’s self-
regulating, homeostatic mechanism to become activated in order to
initiate any needed repair (Schultz and Luthe, 1969). This training is
designed to enhance self-regulatory mechanisms for counteracting
the effects of stress. It consists of exercises that primarily focus on
heaviness and warmth in the extremities. This highly advanced relax-
ation strategy is based on a strong psychophysiological theory of ten-
sion reduction and self-regulation. Schultz and Luthe (1969) stated
that the purpose of autogenic training is to bring about a shift from an
anxiety state to the autogenic state, which facilitates and mobilizes
the recuperative and self-normalizing brain mechanisms. Luthe (1979)
reported that autogenic training can be highly effective in the treat-
ment of several stress-related disorders such as rheumatoid arthritis,
chronic pain, bronchial asthma, hypertension, and gastric ulcers.
Autogenic training consists of six standard exercises. These exer-
cises primarily emphasize warmth and heaviness in the extremities,
regulation of cardiac activity, respiration, abdominal warmth, and fi-
nally cooling of the forehead (Schultz, 1932). Pelletier (1979) stated
that autogenic training is the most comprehensive method of relax-
ation and can serve as a model for all others that address themselves
to clinical treatment of pain and stress-related disorders. Labbe and
Williamson (1984) found autogenic training to be highly effective in
the treatment of common and classical migraine headaches. The sub-
jects in this study maintained their improvements in a six-month fol-
low-up study.
Breathing Exercises
Almost all relaxation techniques incorporate breathing exercises.

Benson (1975) observed that all traditional forms of meditation begin
with breathing. It is believed that breathing techniques directly influ-
ence the functioning of the autonomic and the central nervous sys-
tems and can play an important role in inducing a state of relaxation.
On the other hand, improper and shallow breathing can increase mus-
cle tension and may result in an agitated state. Most panic or anxiety
attacks have been related to improper breathing habits. Smith (1989)
stated that breathing plays a central function in relaxation training be-
cause it is a “natural barometer” which can provide the person with
information about his or her state of tension and relaxation. Also,
breathing exercises by themselves can promote a meditative state that
can be highly peaceful and rejuvenating.
A simple but highly effective form of breathing-relaxation tech-
nique is counting one’s exhalations. The purpose of this technique is
to bring full attention to breathing and to quiet mental activity. All
that matters is the counting of the exhalations. As soon as a thought is
perceived or recognized, the attention is guided back to the breath and
the counting. If one persists in the practice of this technique, he or she
is likely to notice a significant degree of tension reduction both men-
tally and physically. One application of this technique is to combat
insomnia, especially when difficulty with falling asleep seems to be
the issue.
Imagery Techniques
Imagery techniques are commonly used forms of relaxation that are

often combined with other stress-reduction strategies (Lavey and Tay-
lor, 1985). Achterberg (1985) defined imagery as mental processes that
summon and utilize the five senses, vision, audition, smell, taste, and
touch. Because imagery primarily focuses on cognitive/mental phe-
nomena, Davidson and Schwartz (1976) state that it may have some
limitations when reducing somatic or bodily tension. To rectify this,
one may wish to combine imagery with other forms of relaxation such
as breathing or progressive relaxation.
Lazarus (1985) suggested that imagery exercises not only result in
a deeper state of relaxation, but they have also been shown to enhance
alertness to ongoing feedback from autonomic and muscular sys-
tems. Pelletier (1979) reviewed several studies in which imagery
techniques were shown to have successfully affected cancer growth.
He concluded that imagery may be a powerful method in treating var-
ious stress-related illnesses. Imagery is often combined with other

forms of stress management to enhance one’s ability to avoid nega-
tive or self-damaging thoughts. As described previously, visualiza-
tion and imagery can be highly helpful in stress-inoculation training
and the process of cognitive restructuring. Imagery exercises are par-
ticularly used by sports psychologists who have found them highly
effective in reducing stress and anxiety related to performance (Neiss,
1988).
Progressive Relaxation
Progressive relaxation is one of the most popular and widely used

forms of relaxation. The technique was originally developed by
Edmund Jacobson (1938) who studied the importance of rest and re-
laxation in the treatment of stress-related disorders.
Jacobson (1938) theorized that a reduction of muscle tension
would lead to a reduction of autonomic nervous system activity, espe-
cially sympathetic activity. Progressive relaxation is comprised of
two major steps: (1) learning to identify excessive tension in certain
muscles; and (2) learning to reduce and, if possible, eliminate that
tension. First, the muscle is contracted and held tense for a moment
so as to help individual learn to identify the sensation of tension. The
individual is then told to relax the muscle to experience the sensation
of relaxation. This procedure is repeated with various muscle groups
of the body (Olton and Noonberg, 1980). Wolpe (1958) drew upon
Jacobson’s model of progressive relaxation and theorized that a con-
dition of muscle relaxation would be incompatible with an anxiety re-
sponse. Based on this assumption, Wolpe initiated the use of progres-
sive relaxation in systematic desensitization for treatment of phobias
and some psychosomatic disorders (Woolfolk and Lehrer, 1984).
Transcendental Meditation
Meditation is a method of relaxation that has been practiced in the

East for thousands of years. In the West, the most widely practiced
and extensively studied form of meditation is transcendental medita-
tion (TM), which was adopted from Indian Yogic traditions (Benson,
1975). The TM method is deceptively simple to perform and is easily
learned. It consists of assuming a comfortable position with eyes

closed and silently repeating a special sound or word which is re-
ferred to as a “mantra.” A mantra is a Sanskrit word derived from the
Hindu scriptures and has a special significance to the mediator. In the
traditional practice of this approach, one is required to meet with an
adept, highly qualified teacher to receive a personalized mantra to use
during the practice of the technique. Also, additional instructions are
needed for the appropriate practice of this form of meditation that can
be provided only by the teacher.
As a result of extensive psychophysiological research with TM,
Benson (1975) found this technique highly effective in treating hyper-
tension as well as a variety of cardiovascular complications. The two
modern forms of meditation that are based on TM, and whose effec-
tiveness have been supported empirically, are the relaxation response
(Benson, 1975) and clinically standardized meditation (Carrington,
1977). Benson’s technique has in a sense demystified transcendental
meditation by suggesting that instead of repeating a “secret mantra”
one can achieve the same physiological results by repeating a simple,
one-syllable word such as “one,” or “peace.” In addition to repeating
a simple word, Benson suggests three other ingredients for effective
meditation: a relaxed posture, a quiet place, and a passive attitude. An
additional item that needs to be added to this list is regular practice,
without which the effects of this or other techniques are likely to be
unnoticed.
Yoga Training
The word Yoga is derived from the ancient language of Sanskrit,

Yuj, which means to join or bind (Vahia and Doongaji, 1977). Similar
to several other relaxation procedures, this approach focuses on mind-
body integration. According to sacred Hindu texts, the practice of Yoga
brings about a state of total tranquility and allows one to transcend the
limitations of the material universe. According to the Bhagavad Gita,
“When his mind, intellect and self are under control, freed from restless
desire, so that they rest in spirit within, a man becomes one in commu-
nion with God. . . . He who has achieved this shall not be moved by the
greatest sorrow. This is the real meaning of Yoga, a deliverance from
contact with pain and sorrow” (in Iyengar, 1972, p. 20).
There are a number of different yoga techniques, also called paths,

which attempt to bring about a uniting of the body and the mind.
These include Kundalini Yoga, which attends to the body’s energy
centers; Bhakti Yoga, which emphasizes primarily prayer and heart-
felt devotional practices; Raja Yoga in which mastery over the self is
achieved through total stillness and silence; Karma Yoga, which
achieves unity through work, good deeds and serving others; Jnana
Yoga, which underscores reading and meditating on the Hindu scrip-
tures and gaining knowledge through such means; and finally Hatha
Yoga, which is the most well-known form of Yoga in the Western
world, and which focuses on assuming certain positions, conducive
to profound relaxation (Rama, 1985). The various paths of Yoga are
often combined to achieve self-mastery and transcendence.
Patel (1984) considered Hatha Yoga to be a way of improving
health and self-control, and decreasing the harmful impact of envi-
ronmental influences. The key activity underlying yoga exercises is
the focused stretch. Various muscle groups are gently stretched and
unstretched while rhythmic breathing is maintained. Focused breath-
ing is an important aspect of this form of training. Patel (1984) found
Hatha Yoga training to be especially effective in treating essential hy-
pertension, heart disease, and bronchial asthma. Vahia and Doongaji
(1977) found Yoga training to be highly effective in treating various
stress-related disorders, such as gastrointestinal disorders, headaches,
arthritis, and others. Finally, Schultz (1950) stated that Hatha Yoga
enhances muscle relaxation, improves circulation, sharpens concen-
tration and brings about an overall state of rest and relaxation.
MODELS OF RELAXATION
Several important questions need to be asked at this point: Are all

relaxation techniques the same? Do they all produce the same ef-
fects? And finally, which one is the best technique for me? Although
many books on relaxation techniques do not simply address the theo-
retical models of relaxation procedures, I strongly feel that it is im-
portant for the reader to have an understanding of some of these
models and to have a greater knowledge as to why certain techniques
are best for different people at different times.
The underlying formulations by which relaxation techniques pro-

duce their results fall into one of two categories or models. The first
model is based on a unitary model of stress and relaxation. This model,
presented by Benson, Beary, and Carol (1974), stated that all relax-
ation techniques produce a common integrated, relaxation response,
which is the opposite of an aroused or activated state. According to
Benson (1975), the relaxation response results in a reduced metabolic
state which is consistent with decreased autonomic system activity.
As discussed earlier, this means that there tends to be a marked de-
crease in oxygen consumption and carbon dioxide elimination, a
reduction in the concentration of blood lactate, and a lowering of car-
diac and respiratory rates (Benson and Friedman, 1985). Benson
(1975) argued that since all relaxation/meditation procedures can
bring on the same general effects, the best procedure would be the
least difficult one to learn and to teach. A simple technique espoused
by this camp is repeating a simple word with each exhalation as a way
of inducing this relaxation response.
English and Baker (1983) investigated the efficacy of progressive
relaxation, transcendental meditation, and a control condition in re-
ducing blood pressure and heart rate, before, during, and after immer-
sion of a hand in cold water, which was defined as the stressor. Both
relaxation groups showed significant reductions in blood pressure,
but not heart rate across the treatment intervals. This and similar stud-
ies have suggested that techniques such as progressive relaxation and
transcendental meditation mobilize similar psychophysiological mecha-
nisms and result in one generalized “relaxation response.”
An alternative model of relaxation that has been conceived by
Davidson and Schwartz (1976) is the multiprocess model. According
to this model, relaxation procedures are divided into two general cat-
egories of somatic (focusing on the physical activity) and cognitive
(focusing on the mental activity) relaxation. This categorization is
based on the premise that somatic and cognitive elements of arousal
would respond differently to various relaxation techniques. It is be-
lieved that those relaxation procedures which influence physical or
somatic processes will be effective in the reduction and the treatment
of somatic tension. On the other hand, techniques that affect cogni-
tive events are likely to reduce cognitive overactivity or anxiety
(Davidson and Schwartz, 1984).
To illustrate the distinction between somatic and cognitive anxiety,

Davidson and Schwartz (1976) provided the example of a person who
is physically relaxed but cannot fall asleep because his or her mind is
overactive. As defined by this model, this person is said to be experi-
encing cognitive symptoms of anxiety. Alternatively, somatic anxiety
may be viewed as the characteristic of the person who experiences
physical tension and discomfort without the cognitive symptoms
(e.g., negative thoughts, worries). Schwartz, Davidson, and Goleman
(1978) labeled progressive relaxation as a somatically oriented tech-
nique because it requires paying attention to physical sensations and
muscle tension. Conversely, they conceived of mantra meditation (re-
peating or focusing on a word), such as transcendental meditation, as
a cognitively oriented technique since repeating the mantra is likely
to result in reducing constant cognitive activity.
Oringel (1983) compared somatic versus cognitive processes in re-
laxation training. Subjects received three sessions of either somatic
(progressive) relaxation, cognitive relaxation (guided imagery), or a
placebo procedure. The result supported the belief of somatic versus
cognitive anxiety. Cognitive anxiety subjects showed more tension as
measured by electromyography (a method of measuring muscle ten-
sion) than did the somatic subjects. The somatic subjects reduced
muscle activity levels more than cognitive subjects did. No signifi-
cant changes were observed in the placebo group. Elsewhere, Woolfolk
and Lehrer (1984), in their extensive review of the literature on differ-
ent relaxation modalities, concluded that meditation and progressive
relaxation appear to have significant differences in their effects.
From a clinical standpoint, especially when it comes to the treat-
ment of chronic pain, I prefer the multiprocess approach to relax-
ation. The multiprocess approach can be quite helpful to patients who
cannot figure out why a technique works at certain times and may ac-
tually cause tension at another time. For example, a few years ago, a
colleague of mine who extensively uses biofeedback in his practice
consulted with me about a difficult case in which his extremely suc-
cessful and pleasing imagery technique was actually making one of
his patients more tense and even agitated. After discussing the pa-
tient’s history, it became obvious that the patient was experiencing
such high levels of physical pain and tension that focusing on mental
imagery was almost useless, because as the patient later remarked,
“No matter how hard I try I can’t seem to visualize the beach because
my pain says that I am stuck right here.” This patient needed a more
somatic technique focused on reducing his physical tension. As this
was accomplished, the patient was more inclined to consider pleasant
visual images or thoughts.
Many patients throughout the years have related that they had diffi-
culty using techniques such as transcendental meditation to reduce
their pain because their physical symptoms were so distracting. After
a while they became so frustrated that they had to simply drop out of
therapy. I am by no means suggesting that such techniques should not
be attempted by chronic pain sufferers. However, if they do not work
for one person, it does not mean that he or she should give up on relax-
ation training altogether or conclude “I just can’t do it.” The problem is
very likely with the technique—or possibly because the individual has
not given it enough time to work.
SUMMARY
Considerable evidence supports the effectiveness and strength of

relaxation techniques in combating pain and stress-linked complica-
tions. Also, it may be concluded that psychological and physiological
changes that are brought about as a result of the practice of these tech-
niques are long lasting, and stand the test of time. During the last sev-
eral decades there has been a debate over whether different forms of
relaxation procedures have unique effects or whether they all produce
a single, generalized relaxation response. The unitary and the multi-
process models attempt to answer such questions and explain the na-
ture of relaxation therapy. Although there is some support for each of
these models in the treatment of chronic pain, it may be important to
choose a technique that addresses both physical and mental sources
of tension and anxiety.
Based on my research and clinical experience, I have concluded
that the autogenic technique addresses both somatic and cognitive
sources of tension and can be effectively used as a means of coping
with chronic pain. This is the only technique that has benefited from
nearly a century of close scientific scrutiny and the only one that has a
scientific explanation for how and why it works. As Pelletier (1979)
has stated, autogenic training “is the most comprehensive [technique]

and can serve as a model for all others that address themselves to the
clinical treatment of mind-body disorders” (p. 121).
In following chapters the reader will have an opportunity to learn
about the intricacies of this technique, and will be provided with de-
tailed instructions on how to use the technique to effectively reduce
and manage pain, and to enhance sleep. Almost everything a practi-
tioner needs to know about this technique is included in this book. I
ask only that the reader closely follow the instructions for each step of
the training.
PART II:
HISTORY AND PRINCIPLES
OF AUTOGENIC TRAINING
Chapter 4
Autogenic Training:
Its History and Basic Principles
Autogenic training is the oldest Western approach for facilitating

self-regulation and promoting recovery from psychophysiological
symptoms and disorders. This technique was originally developed by
the German neuropsychiatrist, Johannes Heinrich Schultz (Schultz,
1932; Schultz and Luthe, 1959), and was introduced to the medical
community in the early 1920s. Although this training has gained
much popularity and recognition, especially in Europe and Japan, it
suffers from a lack of recognition by researchers and clinicians in the
United States. This may be partially because much of the literature on
the subject remains in German. Although attempts are continually
being made at translating some of the original manuscripts and the re-
search findings, a wealth of knowledge remains untapped. Another
reason for the lack of proliferation of the training is the recent empha-
sis on quick techniques that can be easily taught and learned. Auto-
genic training is not such a technique. It is a series of potent therapeutic
exercises that can make a significant contribution to promoting health
and well-being—it is not merely another relaxation exercise. In fact,
one must note that Schultz and later his protégé, Luthe, defined
autogenic training as a psychophysiological form of therapy, a thera-
peutic approach that addresses itself to the mind-body interconnec-
tions and intercommunications (Schultz and Luthe, 1959).
THE BIRTH OF AUTOGENIC TRAINING
The birth of autogenic training can be traced to the latter part of the
1800s and the pioneering work of the prominent neuropsychiatrist,
55
Oskar Vogt. Vogt devoted his life to research and exploration in the
area of body-mind (somato-psychic) medicine (Luthe, 1977; Schultz
and Luthe, 1969). His research in the areas of hypnosis, hypno-
analysis, and sleep provided important knowledge regarding the
brain’s many mysteries, particularly as applied to self-regulation and
psycho-physiological maintenance. Vogt’s observations about mind-
body interactions were so astute and advanced that even today’s sci-
entists would find some of his findings accurately supportive of the
latest discoveries in medicine. His research clearly suggested that
what is referred to as “mind-body dichotomy” is indeed a unified en-
tity that cannot be fully researched in a linear, reductionistic fashion.
Indeed, the person as a whole is greater and different than the sum of
his or her parts.
Among other areas of exploration into the self-regulatory activities
of the nervous system, Vogt and his collaborator, another brilliant
psychiatrist and neuropathologist, Korbinian Brodmann, became in-
terested in the many functions of sleep, especially in terms of its
psychophysiological, recuperative properties (Luthe, 1973). Hypno-
sis, they conjectured, was a logical method of exploring the body’s
self-healing properties. Hence, they began researching a variety of
hypnotic, autohypnotic, and hypnoanalytic techniques and proce-
dures. Brodmann was particularly responsible for developing a form
of hypnosis, called fractioned hypnosis, which further explored the
various psychophysiological changes during the hypnotic state. This
line of research later enabled them to develop some of the earliest
conceptualizations with regard to the various stages of sleep (Schultz,
1950).
At the same time, Vogt, his wife Cecil, and some of their collabora-
tors continued to delve into the many mysteries of the brain from both
structural and functional standpoints. In time, it became more and
more obvious that by activating certain natural processes within the
nervous system, a state of balance and recovery could be achieved,
particularly after exposure to stress and trauma. Specific exercises
called prophylactic rest-autohypnosis were developed to promote
such healing processes. After practicing these techniques, patients
began to spontaneously recover from a variety of physical and emo-
tional disorders (Luthe, 1973).
Autogenic Training: Its History and Basic Principles 57
Meanwhile the young physician Johannes Heinrich Schultz, who

had training in internal medicine (Richard Stern and Paul Ehrlich In-
stitutes), dermatology, and neurology, became interested in Vogt’s
work with mind-body regeneration techniques. Shortly after his asso-
ciation with his brilliant mentor, Schultz began his exploration of
hypnosis and its applications in the treatment of psychosomatic dis-
orders. He was, however, aware of and sensitive to some of the unde-
sirable aspects of hypnotic and hypnotherapeutic techniques such as
dependence on the therapist, the need for passivity, and hypno-
tizability (Lindemann, 1973). By the early 1900s, Schultz became
convinced that through the use of some basic training, he could teach
his patients to benefit from a brain-directed, self-regulatory process
to improve their psychological and physical health. This process of
activating the body’s natural repair and regulation mechanism came
to be known as autogenic therapy, or a self-generated process of re-
pair and healing.
Early observations regarding this process of repair and regenera-
tion suggested the experience of heaviness and warmth in the extrem-
ities while the patient was experiencing a pre-sleeplike state of
profound relaxation. Schultz attempted to induce a similar state in his
patients by having them repeat simple formulas (phrases) that fo-
cused on the experience of heaviness and warmth in the arms and the
legs. The patients learned to quickly induce these sensations merely
by repeating the formulas and concentrating on a sensation of heavi-
ness and warmth, with the passive, or nonvolitional, concentration on
the formulas playing a key role in achieving the autogenic state (see
Chapter 6 for a detailed explanation of passive concentration). Soon
it was discovered that by focusing on additional formulas, which sug-
gested a calm heartbeat, regular breathing, abdominal warmth, and
finally, a cool forehead, the depth of the relaxation process and replen-
ishment of the physiological resources could be profoundly en-
hanced. In time, these came to be known as the Standard Autogenic
Training Exercises. As a result of practicing these exercises, a neuro-
physiological “key,” or an activating mechanism was discovered
which brought on a shift from an active and/or stressed state to a pro-
found state of repair—a state of recovery which reestablished the
body’s homeostasis. One other especially important discovery was
that after a short time, the subject could learn to benefit from the
training with little or even no dependence on the therapist. This inde-

pendence from the therapist came to be known as one of the hall-
marks of autogenic training.
Both Vogt and Schultz made a most significant discovery: the
brain had the ability to effectively correct and eliminate a variety of
psychophysiological disorders brought about by imbalances within
the nervous system. Hence, the term autogenic embodies two indivis-
ible principles. First, autogenic training encompasses all the inborn
capabilities of the nervous system that make it possible to bring about
the optimum state of balance and health. Second, since such changes
are self-generated the reliance on the therapist is minimized. Ba-
sically, and at least initially, the task of the therapist is to train the pa-
tient to activate such internal, self-regulatory mechanisms so as to
effectively combat disease and internal disharmony.
Indeed, it is a most persuasive discovery that nature has provided
our bodies with the necessary ingredients for promoting health that
require little intervention from the outside to accomplish this task
(Luthe and Blumberger, 1977). However, due to ongoing exposure to
daily stress, various physical and psychological traumas, over-medi-
cation, and ineffective or even damaging interventions (e.g., unneces-
sary invasive procedures), we continue to weaken the body’s self-
healing mechanisms. Fortunately, with approaches such as autogenic
training, the body’s own self-recuperative capabilities can be further
enhanced, and the state of inner balance reestablished.
A psychophysiologically based, corrective phenomenon often ex-
perienced during the practice of autogenic exercises is autogenic dis-
charges. This phenomenon may assume a variety of forms and may
include experiences such as muscle twitches, sudden appearance of
headaches, and physical discomfort. It has been postulated that the
main purpose of autogenic discharges is to release disturbing neuronal
buildup as a way of restoring normal brain functions (Schultz and
Luthe, 1959). In other words, such phenomena are attempts at un-
loading unpleasant and traumatic experiences that may be interfering
with appropriate neurophysiological activity, resulting in a variety of
symptoms. If autogenic discharges persist in their occurrences, it is
necessary to address them by temporarily discontinuing training and
exploring the nature of such experiences.
Some of the more advanced autogenic techniques address such

phenomena from a psychotherapeutic standpoint. Autogenic abreac-
tion, for example, is a method of treatment whereby the trainee is
asked to passively disclose his or her negative experiences from a
spectator’s point of view without any active involvement in the expe-
rience at all (Luthe, 1979). This approach often addresses and may
promote the resolution of deeper issues that may be causing the un-
pleasant, psychophysiologically based episodes (for a more exten-
sive treatment of this subject see Luthe, 1973).
ELEMENTS OF THE AUTOGENIC PROCESS
In his early research, Schultz discovered two principal elements in

the activation of the autogenic process. These were: (1) mental repeti-
tion of specific formulas (phrases) which focused on sensations of
heaviness and warmth in the extremities (consistent with sensations
experienced during hypnosis and shortly before falling asleep); and
(2) the need for the patient to achieve and maintain an attitude of de-
tachment and indifference toward any outcome that may be brought on
by the repetition of the aforementioned formulas. This state of “pas-
sive concentration” is crucial in allowing the brain-directed, self-reg-
ulatory mechanisms to function optimally (Schultz and Luthe, 1959).
If the concept of passive concentration is not adequately and effec-
tively implemented by the patient, the repetition of the various for-
mulas may actually bring about opposite results. That is to say, if the
person forces himself or herself to experience heaviness or warmth,
he or she may actually become more tense and stressed. We shall re-
turn to this important concept later in Chapter 6.
Although autogenic training was initially conceived in terms of
psychophysiological phenomena occurring during hypnosis and self-
hypnosis, it is important to note that extensive electroencephalographic
studies have demonstrated, time after time, that the autogenic state is
unique and different from the hypnotic state. Luthe (1970a) empha-
sized this point by making the following statement:
. . . The steady stream of research provided has provided in-
creasing evidence that autogenic training is associated with a
specific combination of multidimensional changes which are
not identical with those observed during hypnosis or sleep. A

variety of more recent findings even indicate that a number of
physiological changes take functional directions which are dia-
metrically opposed to those seen during hypnosis. This develop-
ment cannot be overlooked, and in the view of the knowledge
resulting from advancing research, it must be pointed out that
autogenic training can no longer be regarded as a form of hyp-
nosis which is practiced without the hypnotist. Likewise, on the
basis of relevant findings, it is not justified and it would be con-
fusing to continue to use the term “autohypnosis” in connection
with autogenic training. (p. 104; emphasis added)
It must be noted also that while the autogenic state shares some
similarities with the recuperative changes that occur during certain
stages of sleep, it is not a sleep state.
Autogenic training may be best described as a pre-sleep state with
unique psychotherapeutic and psychophysiological properties that
are brought on by observing certain training requirements, such as
passive concentration, and through the daily practice of the standard
training formulas (Luthe, Jus, and Geissmann, 1965).
Nearly a century has passed since the field of autogenic training be-
gan its experimental and clinical sojourn as a method of enhancing
health and well-being as well as combating the ever-deleterious expo-
sure to long-term stress. There are literally thousands of published stud-
ies attesting to the effectiveness of autogenic training and the following
areas and studies may be considered:
• treatment of pain (Blacker, 1980)
• treatment of insomnia (Coursey et al., 1980)
• treatment of night terrors (Sadigh and Mierzwa, 1995)
• treatment of posttraumatic nightmares (Sadigh, 1999)
• Raynaud’s disease (Freedman, Ianni, and Weing, 1983)
• treatment of myofascial trigger points (Banks et al., 1998)
• headaches (Janssen and Neutgens, 1986)
• infertility (O’Moore et al., 1983)
• anxiety disorders (Banner and Meadows, 1983; Sakai, 1997)
Many authors in the United States have lamented that autogenic
training has not received the attention it deserves (Lichstein, 1989;
Pelletier, 1977). Pelletier (1979) suggested that AT can serve as a

model for all relaxation and meditative techniques that attempt to
treat stress-related disorders.
Autogenic training has been taught in medical schools in most Eu-
ropean countries such as Germany, Switzerland, France, Belgium,
Spain, Italy, Poland, and also extensively in Japan (Luthe, 1965).
Many authors have suggested that only a fraction (10 to 20 percent)
of the clinical publications on this technique have been translated into
the English language. Another possible explanation for the lack of
recognition of this psychophysiological approach may be the empha-
sis that is placed on pharmacological treatments in the United States.
Also, much like all behaviorally based techniques, it takes some time
for the effects of autogenics to be noticed and appreciated by the
trainee. However, once the technique has been mastered, its recupera-
tive properties can be easily summoned in minutes of concentrated
practice. Jencks (1977) suggested that some of the almost immediate
(in roughly two weeks) benefits of this technique that can be experi-
enced by the patient include a reduction in anxiety, improved sleep,
enhanced memory, and an improvement in the ability to cope with
daily stress. Gradually and with focused practice, improvements in
coping with pain, cardiovascular and gastrointestinal disorders, and
chronic conditions are acquired.
CONCLUSIONS
The main purpose of this chapter has been to provide the reader
with some of the basic principles of the technique of autogenic train-
ing and its clinical applications. Again, it is important to note that this
nearly century-old psychophysiological approach is far more than a
simple technique of relaxation. Indeed, autogenic training may be
viewed as a formidable method of psychotherapy, cognitive restruc-
turing, and behavior modification. Those who have had first-hand
experience with the training and have practiced it for some time, will
attest to the experience of spontaneous physical and psychological
phenomena that are of significant healing potential. Many of these
phenomena are discussed in several texts under the topics of autogenic
meditation, autogenic discharges, and autogenic neutralization (see
Schultz and Luthe, 1969). The study and exploration of techniques

similar to autogenic training should convince us of the self-recupera-
tive potentials of the mind-body connection and the intricate mecha-
nisms involved in such a process. It must be emphasized that a
powerful technique such as autogenic training is, nevertheless, only a
technique and needs to be methodically combined with other medical
and psychological approaches to address patients’ needs. The treat-
ment of chronic conditions, such as chronic pain syndrome and
fibromyalgia pain syndrome, require a systematic, multidisciplinary
approach. Without a doubt, autogenic training can be a worthy and
reliable component of such an approach.
Chapter 5
Autogenic Training:
Medical and Psychological Screening
MEDICAL SCREENING
Meditative or relaxation training in any form should be preceded

by appropriate medical screening. This statement may come as a sur-
prise to some of the readers who might have been especially exposed
to numerous books and articles on relaxation training with no men-
tion of any precautions whatsoever. This is unfortunate since similar
to medications, relaxation exercises can potentially have some un-
comfortable side effects. Lazarus and Mayne (1990) suggest that the
rapid alterations in autonomic activity, especially a decrease in sym-
pathetic tone brought on by relaxation exercises, may result in para-
sympathetic rebound. This rebound is likely to cause a variety of
unpleasant sensations and symptoms. These may include dizziness,
disorientation, headaches, anxiety, and panic attacks, and in some
cases, hallucinations. However, with appropriate screening, educa-
tion, and adherence to certain principles, these side effects can be
avoided.
In the forthcoming pages, as we discuss autogenic training in a
step-by-step fashion, the reader will be provided with detailed infor-
mation about how to perform each exercise. These instructions need
to be followed to the letter. When people have a negative experience
during the practice of meditation or relaxation training, almost with-
out an exception, they tend to stop practicing and are likely to drop out.
Again, this can be avoided and patients can go on benefiting from
these techniques by simply following certain instructions. It is best to
take the necessary time and learn one step at a time than to rush the
63
process and end up avoiding the training altogether. I have observed a

similar phenomenon with those who suddenly decide to lose weight
or get in shape by doing hundreds of push-ups or go for a five-mile
walk the first day. Usually these people are in such pain and discom-
fort by the next day that even the thought of exercising is painful to
them. While the initial intentions were healthy and noble, the out-
come proved to be disastrous. But such outcomes can be avoided and
patients need to be encouraged to take their time while learning the
basics of autogenic training—and for that matter any other exer-
cise—to maximize the extraordinary, health-enhancing benefits it
has to offer.
Due to the potent nature of autogenic training, it is especially imper-
ative that the patient is evaluated by a physician prior to starting the ex-
ercise. People with disorders related to the endocrine system (e.g.,
diabetes, hypo- or hyperthyroidism) must remain under close monitor-
ing of a physician while undergoing this training since significant bio-
chemical changes may occur. Although these changes may be positive
and beneficial, the patients’ physicians need to be aware of the need to
possibly change some of their medications. For example, people with
hyperglycemia who are insulin dependent may, in time, need a lower
dose of insulin because autogenic training can improve their condition
thus necessitating an adjustment in the medication dosage. For a num-
ber of years I have worked with many diabetics who successfully prac-
ticed with autogenic training and benefitted from it considerably
because they followed their physicians’instructions and received regular
checkups. The family physician, especially, needs to be aware of any
steps the patient is taking to enhance his or her health and well-being.
The following medical conditions require physician supervision
while the patient is participating in any form of meditative or relax-
ation training (Luthe, 1979). Even though most people with these
conditions never experience any uncomfortable side effects, and such
side effects are rarely observed in clinical studies, close medical su-
pervision is required to avoid impeding the therapeutic progress.
1. Seizure disorders of any kind (petit or grand mal, etc.)

2. Labile blood pressure
3. Diabetes mellitus
4. Thyroid disorder of any kind (hyper or hypo)
Autogenic Training: Medical and Psychological Screening 65
5. Severe asthma
6. Glaucoma
7. An actively bleeding stomach ulcer
The autogenic technique should also be used with caution after a

heart attack or the experience of a profound trauma. In such cases, it
may take a few weeks before the patient can optimally benefit from
relaxation training. Even then, I highly recommend a gradual, “small
dose” approach, with sessions lasting somewhere between five to ten
minutes, to be followed by a few minutes of discussing physical and
emotional experiences and sensations.
PSYCHOLOGICAL SCREENING
There are also a few psychological conditions that need to be kept

in mind prior to relaxation training. Although common sense dictates
that a person who is extremely anxious or disturbed needs to relax,
practicing relaxation techniques may actually cause greater anxiety
and the experience of a phenomenon known as relaxation-induced
anxiety may result (Heide and Borkovec, 1984). This is a real phe-
nomenon that may be experienced by those who force themselves or
try too hard to relax when they are extremely agitated or distressed. It
is also possible that a patient may experience profound levels of re-
laxation-induced anxiety because of the fear of losing control. In
addition, a weakened ego-defense mechanism as a result of a trau-
matic experience or exposure to prolonged, unremitting stress may
predispose a person to the experience of such relaxation-related, dis-
turbing phenomena. In such cases, counseling or pharmacological in-
terventions may be more helpful until the severity of the symptoms
have at least somewhat subsided. Relaxation exercises should not be
attempted during panic attacks. However, prior to an attack or after-
ward, relaxation exercises may be most beneficial.
Those who may present with symptoms suggesting a loosening of
the ego boundaries need to be further examined and may be consid-
ered for other forms of treatment before training in the autogenic
technique. Following is a list of psychological symptoms and diagno-
ses that should be kept in mind prior to the training (Luthe, 1979).
Once again, if a patient is currently experiencing any of these symp-

toms, make sure that his or her condition is being monitored by a phy-
sician and/or mental health professionals.
1. Severe anxiety
2. Major depressive illness
3. Active psychosis
4. Severe manic episode
5. Dissociative identity disorder (during the active phase)
6. Severe distress shortly after a trauma
7. Thought disorder due to psychological or organic causes
In conclusion, I need to emphasize that if patients are experiencing

any of the previously mentioned medical or psychological symp-
toms, this does not mean that they cannot practice autogenic training
or other relaxation techniques. However, they need to be under physi-
cian supervision to avoid any negative experiences. As a general rule,
these techniques should not be implemented during severe crises of a
medical, psychological, or interpersonal nature.
When people have been exposed to prolonged levels of physical
and psychological stress, it may be helpful to gradually expose them
to various relaxation techniques to avoid phenomena such as para-
sympathetic rebound. The training sessions, for example, can be
made very brief with focus on physical relaxation, simple phrases, or
breathing techniques. Once the patient begins to feel more comfort-
able and the process of “letting go” is not as anxiety provoking, the
sessions can be made longer. With regard to specific standard autogenic
formulas, attenuated formulas can be used initially to reduce their po-
tency and avoid any unpleasant experiences. For example, in the sixth
autogenic exercise, instead of repeating the standard formula, “my
forehead is cool,” an attenuated version (“my forehead is slightly
cool”) may be repeated to avoid dizziness, or under uncomfortable
reactions by anxious or highly stressed patients. Such helpful instruc-
tions are provided throughout the following instructional chapters
which address specific standard autogenic exercises.
Chapter 6
Requirements for Achieving

the Autogenic State
There are five major requirements for achieving and facilitating the
autogenic state. These are: (1) reducing environmental (afferent) stim-
ulation; (2) passive concentration; (3) making mental contact with a
specific body part or function (for example, breathing); (4) repetition
of specific phrases (called formulas) for a period of time; and (5) prac-
tice of these exercises on a daily basis. In this chapter these require-
ments will be explored in great depth. Prior to starting the training, it is
imperative that the practitioner reads this chapter at least once, and re-
views it from time to time to make sure that he or she is adhering to
these principles that are so central to this training.
To fully experience the effects of the standard autogenic exercises
and to enhance the process of mind-body rejuvenation and repair, all
environmental stimuli (sound, light, etc.) need to be reduced to a min-
imum. Also, specific positional postures recommended by Schultz and
Luthe (1969) will be discussed in this section. I have introduced an
additional posture for the fifth exercise, which has shown to enhance
the achievement of warmth in the abdominal region.
From time to time, I hear people make such statements as, “I relax
best when I am watching television.” Although they may experience
a quieting of their “busy” thinking and television may be an effective
form of distraction, in reality it may actually cause more tension be-
cause of the constant audiovisual stimulation. Research clearly
shows that the most effective way of facilitating a shift from a stress
state into a recuperative-relaxation state is to reduce environmental
and physical sources of stimulation. To fully appreciate the impor-
tance of this critical step, we need to learn some of the basic concepts
67
that were discovered in investigations dealing with sensory depriva-

tion and the restricted environmental stimulation therapies (REST).
LESSONS FROM RESTRICTED

ENVIRONMENTAL STIMULATION THERAPY
In the late 1950s, a group of researchers at McGill University con-

ducted the first systematic research project using sensory deprivation
with human subjects. During the research, subjects were either placed
in a dark, soundproof chamber, or they were immersed in dark tanks
filled with water. Psychophysiological measures of subjects in these
early studies showed profound decreases in arousal levels and sym-
pathetic activity, suggesting a relaxation effect. That is to say, without
practicing any particular relaxation or meditative techniques, these
subjects were able to achieve deep levels of rest and relaxation by
merely being placed in an environment that was free of any form of
stimulation.
However, the initial reactions to such experiments were mixed.
Some viewed sensory deprivation studies as unethical, horrifying,
and dangerous, while others considered them a breakthrough in
better understanding the human nervous system. Several decades
ago, many authors argued that sensory deprivation was an inaccurate
description of these experiments (Lilly, 1977; Weiss, 1973). Whether
the person is resting in a dark, quiet chamber or buoyant in a water
tank, he or she has a variety of sensory sensations. Auditory stimuli
are also received from inside the body. Hence, the term sensory depri-
vation was replaced with “stimulus reduction” or what is now known
as restricted environmental stimulation therapy, or REST for short.
Simply put, REST entails placing a person in an environment with as
little sensory stimulation as possible.
Although there is still a need for further systematic research with
REST, it has been convincingly demonstrated that this approach is a
powerful way of eliciting positive change in a variety of psychologi-
cal, physiological, and behavioral processes (Suedfeld, 1980).
Currently, there are two approaches for achieving restricted envi-
ronmental stimulation. The first approach requires placing the sub-
ject in a dark and soundproof room for approximately one hour. The
Requirements for Achieving the Autogenic State 69
second approach is flotation. The subject is placed in a dark and

soundproof flotation tank filled with buoyant liquid (a liquid with ex-
tremely high salt concentration). The temperature of the liquid is kept
at approximately 95.0°F. Because of the high salt concentration, the
subject can float in a buoyant state during the treatment period which
lasts ten to sixty minutes (Lilly, 1977). The buoyant state signifi-
cantly reduces stimulation from the muscular system to the brain,
which will consequently promote a deeper state of relaxation.
RESTRICTED ENVIRONMENTAL STIMULATION

AND STRESS MANAGEMENT
A person who has been bombarded with stressful stimuli through-

out the day will naturally seek a place of rest and solitude to reduce
the physical and psychological tension that he or she has been experi-
encing. To accomplish this, the individual may retreat to a quiet
room, dim the lights, and close his or her eyes for a short time. Even if
such retreats are brief and temporary, they are likely to bring about
some degree of relaxation and revitalization.
The need for seeking solitude and a quiet place to replenish one’s
depleted resources is by no means a new idea. The Bible, for exam-
ple, is full of examples of how periods of retreat to a “desert” place
can be restorative and highly beneficial. Even in today’s world many
religious and cultural practices require people to spend a brief period
in isolation at some point during the day. Such periods of isolation
have been viewed as necessary for one to maintain and improve one’s
health, and also to experience a state of higher consciousness.
Although the Western world has been somewhat reluctant to sub-
scribe to such practices and rituals, there is now strong empirical evi-
dence that forms of meditative relaxation which require some degree
of physical isolation can be highly effective in treating pain and
stress-linked disorders. The effortless passive relaxation of REST
may provide an advantage over methods requiring a trial-and-error
approach toward achieving a deep state of relaxation.
One explanation for the effectiveness of REST is that restricted
stimulation has a direct effect on the hypothalamic-pituitary-adrenal
cortex axis activity (HPAC) which was described in Chapter 2. The
HPAC is considered to be an important mechanism that is mainly in-

volved in the stress response. It has been shown that the hypothala-
mus directs the pituitary gland to release several hormones in stress
situations (Selye, 1976). The most critical hormone released by the
pituitary gland in stress situations is the adrenocorticotropic hormone
(ACTH).
The primary function of ACTH is to stimulate the outer layer of the
adrenal glands and the adrenal cortex. The adrenal cortex then pro-
duces and releases cortisol and aldosterone. These hormones are gen-
erally responsible for providing the body with needed energy and
fluid retention in stressful situations. In addition to generating energy
through the process of gluconeogenesis, cortisol can effectively re-
duce inflammation.
As previously discussed, continuous and prolonged secretion of
these hormones, results in structural damage, especially affecting
lean and connective tissue. Another important role of stress hor-
mones is their influence on the immune system. Too much cortisol
significantly suppresses immune activity and if its excessive produc-
tion is prolonged, a dysfunction of the immune system may ensue.
A study by Turner and Fine (1983) found REST resulted in a sig-
nificant reduction of both ACTH and cortisol levels. These authors
concluded that REST-assisted relaxation produces a state of relax-
ation that is associated with significant decreases in the pituitary-ad-
renal cortex activity. Also, Lilly (1977) reported improved cognitive
functioning in subjects who received REST for several sessions.
REST has also been used successfully in the treatment of hyperten-
sion, eating disorders, and a variety of psychosomatic disorders.
THE FIRST REQUIREMENT: REDUCING

ENVIRONMENTAL STIMULATION
By following specific requirements established by the pioneers in

autogenic training, patients can achieve a state of reduced environ-
mental stimulation without needing a flotation tank or an isolation
chamber. First, at least during the initial phases of training, patients
need to find themselves a quiet room (as noise free as possible) where
they will not be disturbed for at least twenty to thirty minutes, the
length of a standard exercise. They may use a sign on the door, if nec-
essary, to inform others that they do no wish to be disturbed. It is also
important to close the drapes and dim the lights to the lowest possible
levels and turn off phones and pagers.
Positions for Relaxation
The next step is to reduce physical stimulation by finding a posi-

tion that places the least amount of tension on muscles and joints.
First, patients need to be instructed to loosen all tight clothing, loosen
belts, and remove shoes if necessary. Second, they need to discover a
postural position that is most agreeable to them. Most people find it
helpful to lie on their back on a couch or a comfortable bed. This po-
sition may result in tension in the muscles of the lower back which
will undoubtedly interfere with the ability to achieve the autogenic
state. To remedy this, patients should be encouraged to experiment by
placing pillows under their knees until their lower back muscles are
in a neutral or stress-free position. The arms should be placed slightly
away from the trunk in a comfortable, “unlocked” position.
Next, attention must be paid to the position of the neck. A soft pil-
low may be used to place the muscles of the neck in a relaxed posi-
tion. To avoid overextending or flexing the neck experiment with
pillows of varying sizes. Photo 6.1 depicts a comfortable horizontal
position. One of the drawbacks of this position, usually during the
earlier stages of training, is that some people tend to fall asleep while
practicing the exercise. To avoid this, the individual may choose one
of the sitting positions.
The first sitting position (Photo 6.2) requires the use of a reclining
chair with a high back and comfortable armrests that are neither too
high nor too low. If the armrests of the recliner are uncomfortably po-
sitioned, a possible remedy may be to use pillows or towels to dis-
cover a position that is least stressful to the arms and the shoulders.
Another problem with recliners is that they may place undue stress
under the lower calves. Again, a soft pillow may be the solution.
Finally, the muscles of the lower back may be quite vulnerable in a
reclined position because of the lower back extension that such chairs
tend to promote. Pillows or rolled up towels may be used to reduce
PHOTO 6.1. The Horizontal Position
PHOTO 6.2. The Reclined Position

the stress on the lower back muscles. In my office I have several pil-
lows that I use to make sure that the recliner fits the needs of all pa-
tients. With each patient, the recliner is transformed into a custom-
made chair that promises the most comfortable position. Take your
time and experiment. The outcome of each training session may be
significantly improved by finding out which positions work best for
the patient.
Another sitting position which is of pragmatic utility is presented
in Photo 6.3. To best benefit from this position, patients need to make
sure that their feet are firmly placed on the floor. Next, they need to
comfortably place their arms in their laps, with the palm of the hands
facing down. Next, the head and the trunk may be dropped forward
until a stress-free, relaxed position is achieved. Patients need to be
cautioned not to place their upper body weight on their arms. If done
correctly, the torso should comfortably balance the upper body’s
weight. This postural position may be used at work or when neither a
PHOTO 6.3. The Sitting Position

bed nor a recliner is available. The position is also excellent for the
abbreviated exercises which will be discussed later on.
A specific position is highly recommended for the third standard
autogenic exercise, which focuses on cardiac activity. To best achieve
the objectives of this exercise, the patient is asked to assume the hori-
zontal position (see Photo 6.4). The next step is to comfortably place
the right hand on the chest region, slightly to the left. To achieve this
position with the least amount of tension, it is best to place a pillow
under the right arm and elevate it slightly so that the arm is raised to
the level of the chest. This position should be used for as long as nec-
essary until the patient can comfortably make contact with the car-
diac activity.
Finally, the horizontal position can be used effectively in the fifth
standard exercise which focuses on generating warmth in the abdom-
inal region. For this particular exercise, patients are asked to comfort-
ably, but very lightly, place their right hand on the upper abdominal
region, right below the tip of the sternum (see Photo 6.5). Again it
may be helpful to place a pillow under the arm in order to minimize
PHOTO 6.4. The Horizontal Position for the Heart Exercise (Note the comfortable
position of the right hand on the chest.)
PHOTO 6.5. The Horizontal Position for the Abdominal Warmth Exercise (Note
the light placement of the right hand on the upper region of the abdominal
cavity.)
any undue stress on arm. This posture can significantly expedite the
objectives of the fifth exercise as will be discussed in Chapter 12.
THE SECOND REQUIREMENT:

PASSIVE CONCENTRATION
As mentioned earlier, passive concentration is a key principle in

autogenic training. This may initially appear to be an obviously con-
tradictory message and one may understandably ask, “How can I
concentrate and be passive at the same time? Doesn’t concentration
require at least some level of active volition?” As we explore the in-
tent of the original developers of this concept, it will become clear as
to what they had in mind by these words and why they made it such a
central concept in this form of psychophysiological training. Mean-
while, it may help to think of passive concentration as an effortless
state of passive focusing or passive attention to a specific task—as if
one is observing a task but is not actively participating in it. Many

people have some difficulty with this concept mainly because they
feel that to make something of value take place they need to be trying
hard. For example, if one wants to develop stronger muscles or to flat-
ten the abdominal muscles, he or she must exercise hard, work at it,
and sweat a lot. A patient recently remarked, “My whole life I was
told that if I wanted to accomplish anything, I had to work hard at it.
Now I am learning that sometimes I can accomplish things without
trying at all.” While trying hard may make sense with regard to devel-
oping strong muscles, the process of psychophysiological repair and
regeneration actually requires the opposite.
If one were to try to force falling asleep, it is quite likely that the re-
sult would be quite disappointing—remaining wide awake hour after
hour. Falling asleep is an effortless process; it cannot be accom-
plished forcefully, which is why it is called “falling” asleep. In other
words, no active participation is required as long as certain conditions
are met; it will happen by itself. The key here is identifying certain
conditions and how one can make sure that they are met efficaciously.
In pages to come, detailed instructions will be provided on how to
promote a state of regeneration and recuperation in its most natural
way. Emphasis will be placed on discovering how people tend to in-
terfere with this natural state of recovery and how autogenic training
can reestablish this process. Meanwhile, we need to spend some
more time exploring the concept of passive concentration or as it was
suggested, passive attention.
Figures 6.1 and 6.2 depict the relative position of the autogenic
state within the wake-sleep continuum. Initially it was conceived that
the autogenic state lay somewhere between wakefulness and sleep,
specifically, in the drowsy state, shortly before falling asleep (see
Figure 6.1) (Jus and Jus, 1965).
However, the growing number of electroencephalographic studies
of the autogenic state provide further and more detailed information
about its occupance within the wake-sleep continuum as seen in Fig-
ure 6.2 (Luthe, Jus, and Geissman, 1965, p. 8). Perhaps the most im-
portant aspect of such conceptualization about where the autogenic
state is located within the continuum is to emphasize the importance
of passive concentration on specific training formulas. For example,
if instead of passive concentration the trainee tries to actively attend
FIGURE 6.1. The General Location of the Autogenic State within the Wake-
Sleep Continuum
FIGURE 6.2. A More Precise Location of the Autogenic State within the Wake-
Sleep Continuum
Source: Luthe, Jus, and Geissman, 1965, p. 8. Reprinted by permission.
to the formulas (for example, to try to make the arms heavier), he or

she is likely to become more alert and experience somatic and cogni-
tive arousal. On the other hand, if the trainee fails to maintain ade-
quate focus on the formulas, he or she is likely to drift into sleep.
Hence, passive concentration plays a critical role in achieving and
maintaining the autogenic state.
Schultz and Luthe (1969) defined passive concentration in the fol-
lowing manner: “[It] implies a casual attitude and functional passiv-
ity toward the intended outcome of [the person’s] concentrative
activity, whereas ‘active concentration’ is characterized by the per-
son’s concern, interest, attention and goal-directed active efforts dur-
ing the performance of a task and in respect to the final functional
result” (p. 14). This brief statement is filled with some very critical
concepts that require our attention. First, it implies that a casual atti-
tude needs to be maintained during each exercise—observing or
watching without active participation. Second, “functional passivity”
further emphasizes that patients should be instructed to avoid any at-
tempt at directly affecting or interfering with the body’s natural func-
tioning. Finally—and the most difficult concept for most people—
“goal-directedness” needs to be dropped from one’s vocabulary dur-
ing the practice of autogenic exercises. Emphasize to patients that

they should refrain from setting a specific agenda at the beginning of
each exercise with regard to their accomplishments such as, “I am go-
ing to raise my hand temperature by ten degrees by the end of the ex-
ercise.” Such an attitude is most likely to have paradoxical effects and
may indeed result in an increase in levels of tension and stress. Con-
sequently, the hand temperature is likely to decrease by the end of the
exercise. Many instances of relaxation-induced anxiety can be effec-
tively avoided by adhering to these instructions.
At the same time, as patients learn to detach from the results of the
exercise during the repetitions of the formulas, they need to learn to
remain focused on the task at hand. This is the concentration or the at-
tention part. If they stop paying attention to specific body parts or
stop repeating a particular formula, it is likely that either they will fall
asleep or become very alert and start thinking about subjects that
have nothing to do with the exercise. Hence, a perfect balance be-
tween passivity and attention to each formula needs to be maintained
throughout each session. Now that we have a better understanding of
passive concentration, let us examine the focal points of one’s atten-
tion.
THE THIRD REQUIREMENT:

MAKING MENTAL CONTACT
WITH A SPECIFIC BODY PART OR FUNCTION
During the standard autogenic exercises, patients are instructed to

pay attention principally to their arms and legs, cardiac activity,
breathing, abdomen, and finally, the forehead. The process of attend-
ing to these body parts is termed making mental contact. That is to
say, mental activity needs to be directed at a particular body part, such
as the right arm, or left leg. This is another critical principle that must
be met for effective training. I often ask my patients to imagine that
they were looking at a body part with their eyes closed. Although this
may appear to be a simple task at first, many, especially chronic pain
patients, have some initial difficulty in accomplishing this. When
people are in pain, they tend to gradually distance or disconnect
themselves from those body parts that are in pain or distress. This
form of distraction will eventually result in exhaustion of their re-

sources because so much of their energy is consumed by trying to
remain detached. To remedy this, prior to the practice of autogenic
exercises I have introduced certain preparatory exercises that should
significantly improve the ability to pay attention to specific body
parts or to “make mental contact” with them. These exercises are de-
scribed in detail in Chapter 7.
THE FOURTH REQUIREMENT:

REPETITION OF SPECIFIC PHRASES (FORMULAS)
The silent repetition of specific phrases, which are referred to as

formulas, constitutes the core emphasis of autogenic training. Schultz
and Luthe (1969) referred to these as “. . . technical keys which,
when applied correctly, unlock or facilitate a psychophysiologic
complexity of brain-directed (autogenic) processes aiming at multi-
dimensional readjustment and gradual normalization” (p. 14). Each
standard autogenic formula is meant to promote a gradual process of
repair, regeneration, replenishment, and balance. Formulas are posi-
tively stated and are repeated in the present tense such as “My right
arm is heavy.” As a particular formula is repeated, patients are asked
to passively focus on specific sensations of heaviness and warmth in a
particular body part. Other formulas focus on calm and regular
breathing or a calm and steady heartbeat.
Some patients may focus on these formulas visually (seeing the ac-
tual phrase before their eyes), acoustically (focusing on the sound of
the phrase) or merely focus on the feelings and the sensations that are
embodied in the formula such as heaviness and warmth. It is also im-
portant to pause briefly between each repetition to better focus on
specific sensations and to further enhance mental contact with a par-
ticular body part. For example, one may think of the following visual
representation while repeating each formula:
My right arm is heavy . . . (pause) . . . my right arm is heavy . . .

(pause) . . . my right arm is heavy . . . (pause) . . . my right arm is
heavy . . . (pause) . . .
Patients are instructed to silently and slowly repeat each formula

five to seven times. Also, a “background” formula that suggests a re-
laxing state may be used in between each standard formula. For ex-
ample, as one moves from the right to the left hand, it may be helpful
to repeat a transitional or a background formula to further enhance re-
laxation. These transitional or background formulas can also be used
to pace the training process and avoid any sudden autonomic shifts
that can result in unfavorable reactions.
The original literature on autogenic training uses the word “tran-
quility” (ruhe in German) as such a background. The English transla-
tions, however, suggest the formula, “I am at peace.” I highly recom-
mend using one of these two while moving from one formula to the
next. These can be instrumental in significantly enhancing the ability
to enter a deeper state of rest and relaxation. Again, it is important to
point out that any active volition (goal orientedness) needs to be
avoided during the repetition of the formulas. Instruct the patient not
to try to “make” anything happen.
Shortly before repeating each formula, the patient must make
mental contact with a specific body part (as implied in the formula).
The repetition of the formula may then commence. Finally, these for-
mulas can serve as an effective anchor during those times when the
mind begins to wander. As soon as distracting thoughts are recog-
nized, one needs to return to making mental contact with the body
part and repeat the formula.
In addition to the standard formulas, I have also introduced several
others which are consistent with the autogenic principles and can be
extremely helpful, especially to those suffering from fibromyalgia,
chronic fatigue, and chronic pain. These will be discussed during spe-
cific chapters which deal with the various exercises.
THE FIFTH REQUIREMENT:

DAILY PRACTICE
As powerful as autogenic training is, without daily practice it is

unlikely, if not impossible, to benefit from its psychophysiological
and therapeutic effects. During the early phases of training, patients
are asked to practice for approximately ten to twenty minutes, twice a
day. To achieve the best possible results, they need to continue prac-
ticing for three to six months. In time, most people will be able to en-
ter the autogenic state after repeating one or two formulas for under
two minutes. To “get there,” they need to practice, practice, and then
practice a little more.
QUICK SUMMARY
To enhance and facilitate the achievement of the autogenic (self-

generated repair) state, certain conditions need to be met. These are:
1. Reducing environmental or afferent stimulation. Patients need

to practice in a dark or dimly lit room with as little noise or
sources of distraction as possible. Second, it is critical to assume
a body position that is comfortable and potentially stress free.
This is referred to as finding the right training positions (pos-
tures). There are five training positions or postures that should
help achieve this objective.
2. Passive concentration. Here the patient is asked to focus on a
particular formula without trying or forcing to make anything
happen. This may be viewed as a state of passive attention—that
is, one’s focus is maintained on the task at hand but he or she is
detached from achieving a certain goal. Use an example such as,
“Think of wanting to fall asleep without forcing yourself to fall
asleep.”
3. Making mental contact. Throughout the autogenic exercises,
patients are asked to pay close attention to a body part or a func-
tion such as breathing or cardiac activity. For instance, when
they are asked to repeat a formula that involves the right arm,
they need to become as aware of that right arm as possible. They
may be asked to imagine looking at their right arm with their
eyes closed. For most people who are suffering from chronic
pain, this may be, at least initially, a difficult task to accomplish,
especially if they are asked to focus on an area that tends to be
painful. To help overcome such impediments, I highly recom-
mend that patients familiarize themselves with the two prelimi-
nary exercises (see Chapter 7) that will considerably improve
the ability to make mental contact with specific body parts and
bodily functions.
4. Repetition of specific phrases. This constitutes the very core of
autogenic training. During each exercise, patients are asked to
repeat specific phrases or formulas that focus on the experience
of certain sensations. Think of these as “keys” to activating the
recuperation and self-repair process. Each formula is repeated
five to seven times with brief pauses between each phrase.
5. Daily Practice. The need for daily practice cannot be overem-
phasized. Patients need to practice autogenic exercises twice a
day, for approximately ten to twenty minutes. As they begin to
master the exercise, it is possible to enter the autogenic state by
repeating one or two phrases, often under several minutes. This
usually occurs after three to six months of consistent, daily
practice.
PART III:
TRAINING, BIOFEEDBACK,
AND TREATMENT OF INSOMNIA
Chapter 7
The Preliminary Exercises
As mentioned in Chapter 6, an important step in promoting the

autogenic state is to make mental contact with specific body parts. One
of Schultz’s techniques for achieving this was to have his patients shake
their hands (one at a time) as vigorously as possible. This was then fol-
lowed by quietly observing the relaxing sensation that ensued after the
shaking. Shortly after this the repetition of the autogenic formulas would
commence. After years of using this technique in clinical practice, I have
discovered that the patient can gain the necessary momentum for effec-
tive and successful practice by learning two preliminary techniques. The
first exercise, which incorporates aspects of progressive relaxation, in-
creases awareness of specific muscle groups through the experience of
gentle levels of muscle tension followed by a close observation of ensu-
ing sensations. The other involves gaining awareness of tension in vari-
ous muscle groups through observation and passive attention. These
techniques need to be practiced for at least two or three sessions and, in
my experience, can significantly improve the ease with which the patient
begins the standard autogenic exercises. (The following instructions
may be read to the patient.)
GENERAL INSTRUCTIONS
Before beginning any relaxation exercise, you need to make cer-

tain preparations. First, spend a few minutes and complete the Pain
Checklist [see Appendix A], Form A. Form B is completed at the end
of each session. This will help you to accomplish two goals: (1) to
gain greater awareness about the intensity of pain in different body
85
parts; and (2) to assess your improvements. These simple forms will
also assist you in developing a better understanding about changes in
your pain and discomfort from day to day. In time, you can share this
information with your physicians and therapists, which should prove
to be of help in further evaluating and treating your condition.
Second, it is imperative that you are not disturbed during these and
the autogenic exercises. Please unplug your phone and if necessary
put a sign on your door to make sure that no one interrupts your prac-
tice time. Sudden interruptions should be avoided at all costs. Third,
make sure that you loosen up any tight clothing— take off your shoes
if you like. Finally, finding the right position is an extremely impor-
tant step that requires some experimentation. [Review the postural
photos in Chapter 6.] Remember, the point of assuming the postures
is to make sure that you are not inadvertently holding your body in a
tense position. Make the necessary adjustments so that your body is
in its most effortlessly relaxed position. If you choose to sit in an up-
right position, make sure that your feet are flat on the floor to ensure
that if you fall asleep during the exercise, you are safely protected
against an accidental fall. Especially during the first few weeks of
training, I recommend that you either use the supine position or the
reclined position. Spend enough time to discover what position
works best for you.
PRELIMINARY EXERCISE I
Now we are ready to begin the first preliminary exercise. While

resting in a comfortable position, take a few deep breaths and as you
exhale, allow your body to sink into the bed or the chair. In a few mo-
ments you may find yourself focusing on different thoughts. This is a
very common experience and although you may initially try to block
your thoughts, you will notice that the more you try to stop your
thoughts, the less successful you become at this task. Therefore, do
not try to fight your thoughts, but as soon as you notice that you are
focusing on anything other than the instructions for the exercise,
gently shift your attention from stray thoughts and bring your atten-
tion back to the task at hand. As you practice this method of passively
refocusing your thoughts, you will notice that, in time, your mind be-
The Preliminary Exercises 87
comes quieter. Meanwhile, remember that you do not need a totally

still mind to perform these exercises.
Now focus your attention on your right hand and your right arm.
Gently press your arm against the surface of the bed or the arm of the
chair. Hold this position for a few seconds and then allow your arm to
go totally limp. Observe any sensations that you might be experienc-
ing in your right hand and arm (it helps to label these sensations, such
as smooth, tired, tense, cold, warm). Shift your attention to your left
hand and arm. Gently press your arm against the surface of the bed or
the arm of the chair. After holding this position for a few seconds, al-
low your arm to go totally limp. Observe any sensations that you
might be experiencing.
We now move to the shoulders and the muscles of the neck. Sim-
ply, and very gently, push your shoulders and neck back—push them
against the back of the chair or the surface of the bed. Hold this posi-
tion for a few seconds and then allow your shoulders to become limp
and relaxed. Observe the sensations in the muscles of your shoulders and
the muscles of your neck. Do not force yourself to relax your shoul-
der or your arms. Merely observe your sensations, which may be sub-
tle or pronounced. Repeat this portion of the exercise twice.
While keeping your arms and shoulders in a comfortable position,
pay attention to the muscles of your jaw. In a very gentle manner,
clench your teeth and hold the tension for five to eight seconds. Then
allow your jaw to sag. Observe any sensations in the muscles of your
jaw and the back of your neck. As we will explore in the next exer-
cise, your upper and lower teeth should never touch except when you
eat. However, most chronic pain patients discover a tendency to
clench their teeth. This can result in pain and discomfort not only
in the muscles of the jaw, but the neck and the upper back as well.
With the help of these exercises you will soon catch yourself when
clenching your teeth. Gradually, and without much thought, you will
be able to avoid a great deal of pain and discomfort.
Now let us move to the lower extremities, the legs and the feet.
Gently press your right leg against the seat of the chair or the surface
of the bed. Hold this position for a few seconds and then allow your
leg to become limp. Observe your sensations. You may then gradu-
ally point your right toes toward your trunk. Please do this very
slowly and hold the tension for a brief time (three to five seconds).
Then allow your foot and toes to become limp. Focus on your sensa-
tions.
Shift your attention to your left leg. Gently press your leg against
the seat of the chair or the surface of the bed. Hold the tension and
then allow your leg to go limp. Observe your sensations. Now gently
point your left toes toward your trunk. Hold this position for a few
seconds and then allow your foot and toes to go limp. Pay attention to
your sensations and allow your body to be calm and quiet. Give your-
self about two minutes before you proceed to the next segment of the
exercise.
Now let us return to the upper extremities. Once again pay atten-
tion to the muscles of your right hand and arm. Without moving your
arm, simply make a fist (not too tightly) with your hand and hold the
tension for a few seconds and then allow your fist to relax and let your
arm become limp. Observe your sensations. Notice if you have diffi-
culty allowing your hand to relax fully. Give yourself about a minute
and then move to your left hand and arm. Make a fist with your left
hand and hold the tension for a few seconds. Then allow your fist to
relax; let your arm go limp. Pay close attention to any sensation that
you might be experiencing in your hand and arm.
While keeping your arms as relaxed as possible, gently shrug and
lift up your shoulders. Hold the tension for a few seconds and then al-
low your shoulders to comfortably relax. Observe your sensations.
See whether your shoulders tend to lift themselves up and become
tense again. Repeat this procedure twice so that you can gain greater
awareness about the levels of tension in these muscles. Again, resist
the temptation to force your shoulders to relax. Simply observe them
as closely as you can.
Let us now move to the muscles of the jaw. If you are suffering
from symptoms of temporomandibular joint disorder (TMJD), it is
critical that you pay close attention to these instructions. Gently open
your mouth as wide as you can without causing any pain. If you no-
tice pain or discomfort, you have gone too far. Close your mouth and
gently start again. The purpose of this exercise is not to see how wide
you can open your mouth but to gain awareness about tension in the
muscles of the jaw. The experience of a slight sensation of tension is
sufficient for this task. After holding your mouth open for five to
eight seconds, allow your mouth to gently close. Again notice that
your upper and your lower teeth should not touch. Observe your sen-
sations; especially note any sensations on your temples and the back
of your neck.
The fifth autogenic exercise focuses on generating a soothing sen-
sation of warmth in the abdominal region. Hence, we need to learn to
pay closer attention to this region. Gently pull in your abdominal
muscles and hold the tension. Do not take a deep breath—simply
hold your breath for a few seconds and as you breathe out allow your
abdominal muscles to relax. Pay special attention to your upper ab-
dominal region. Observe your sensations. Allow your breathing to be
calm and regular.
Now with great care, gently push your abdomen out and arch your
lower back. Please do this very gently and go to the point where you
notice tension but no pain. Hold this position for a few seconds and
then relax. Pay close attention to the muscles of your lower back. For
example, notice the curvature in the small of your back. As you per-
form this exercise, you may notice that the muscles of the lower back
begin to gradually relax and in time the relaxation of the muscles be-
comes very pronounced.
We will now turn to the muscles of the legs and the feet. Gently
stretch out your right leg and then point your toes toward your trunk.
(Just a slight move in the direction of the trunk is sufficient. Do not
force this.) Hold this position briefly and then allow your legs, foot,
and toes to relax and go limp. Pay attention to your sensations. You
may suddenly discover your tired and tense calves through this exer-
cise. Simply observe these sensations.
Then shift your attention to your left leg and foot. Stretch out your
left leg and then point your toes toward your trunk [remember to do
this gently]. Hold this position and then allow your leg, foot, and toes
to relax. Observe your sensations.
You have now completed the first preliminary exercise. Give your-
self a few minutes to enjoy some peace and calm. At this point most
people notice that their mind is not as “busy” or “noisy.” If this is not
your experience, give it time and you will have a quieter mind in a lit-
tle while. When you are ready to get up, please take a few deep
breaths, flex your arms and stretch out your legs, open your eyes, and
gently stand up. Remember, you need to repeat this exercise for sev-
eral days before proceeding to the next preliminary exercise. Take a

few moments and complete the Pain Checklist [Form B].
PRELIMINARY EXERCISE II
During the first preliminary exercise, you gained greater aware-

ness of certain muscle groups by actively tensing and relaxing these
muscles. In this second exercise, you will further enhance your
awareness of these areas by passively making mental contact with
them through a process of focused attention. After a few days of prac-
ticing this technique, you should be ready to more easily and com-
fortably begin the standard autogenic exercises. Remember that it is
best to take these preparatory steps to avoid any frustration during the
advanced part of the training.
As with the first preliminary exercise, find yourself a comfortable
position. Make sure that you are left undisturbed for approximately
fifteen to twenty minutes. Also, make sure that you complete the Pain
Checklist [Form A] prior to beginning your session. Because this ex-
ercise uses a more passive method of making mental contact with
specific body parts, you may notice that initially your mind tends to
wander a little more than during the first exercise. Again, I need to re-
mind you that you should not force yourself to remain focused on the
task at hand. Any forceful attempt at accomplishing the goals of these
exercises will actually result in the experience of greater levels of ten-
sion. Merely refocus your attention as soon as you notice that you
have become distracted.
To begin the exercise, simply close your eyes and take a few deep
breaths. Do not hold your breath. After a deep inhalation, breathe out
and allow your body to sink effortlessly into the bed or the chair. Give
yourself about two to three minutes to settle down and to quiet your
thoughts. Now begin focusing on the muscles of your right hand
and arm (up to your right shoulder). Imagine that you are looking at
your arm with your eyes closed. Breathe naturally and comfortably.
With each exhalation, silently say to your right hand and arm: “Re-
laxed and calm.” Repeat this for three to five breaths. While keeping
your right arm totally still, shift your attention to your left hand and
arm. Again imagine that you are looking at your arm with your eyes
closed. With each exhalation repeat: “Relaxed and calm.” Repeat this
for three to five breaths.
An excellent method of paying attention to the muscles of your
shoulders is to notice how your breathing affects (no matter how sub-
tly) the movement in your shoulders. If you are a shallow breather,
you will notice a greater rate of movement in this area. Do not try to
control your breathing; your awareness of these muscles is all that is
required of you. Breathe naturally and with each exhalation say: “Re-
laxed and calm.” You may notice subtle movements in the muscles of
your neck and a gradual release of tension. Make sure that you do not
interfere with this process. Repeat this for three to five breaths.
We now move to the muscles of the jaw. Begin by paying attention
to whether your upper and lower teeth are touching. Allow your jaw
to sag slightly. Imagine that the force of gravity is naturally pulling
your jaw down, quite effortlessly. Breathe comfortably and naturally.
Exhale through slightly parted lips. With each exhalation silently say:
“Relaxed and calm.” Repeat this for three to five breaths.
Because the third autogenic exercise requires paying attention to
cardiac activity, it is important that you can comfortably become
more aware of the muscles of your chest and then more aware of the
activity of your heart. During this exercise you need to simply pay at-
tention to the muscles of your chest. Again, you may find it helpful to
focus on your breathing and the movement of your chest, or just
imagine that you are looking at the muscles of your chest with your
eyes closed. Most people who are chest breathers will notice more ac-
tivity in these muscles. This will in time change as you begin the
fourth autogenic exercise on breathing. Meanwhile, breathe naturally
and comfortably and with each exhalation silently say to yourself:
“Relaxed and calm.” Repeat this for three to five breaths.
Gaining greater awareness of the abdominal region, especially in-
ternally, is the focus of the fifth autogenic exercise. During the pre-
liminary exercises, we simply pay attention to the abdominal muscles.
Again, simply pay attention to any movements in the abdominal re-
gion as you inhale and exhale. Abdominal breathers will notice much
more movement in this area than in the chest. Breathe naturally and
without trying to interfere with your breathing process. With each ex-
halation, silently say: “Relaxed and calm.” Repeat this for three to
five breaths.
The muscles of the lower back are perhaps the most neglected
muscles in the human body. We pay attention to them only when we
suffer from back pain. Although the standard autogenic exercises do
not offer any special phrases or formulas for the muscles of the lower
back, I have introduced several phrases that focus on heaviness and
warmth which patients have found quite helpful in relaxing these
muscles of the lower back. Hence, it is important to gain a greater
awareness of this area.
Allow your attention to shift to the muscles of your lower back.
Try to focus on the small of your back. Abdominal breathers may find
it much easier to pay attention to this area because the activity of the
abdomen during breathing directly affects the muscles of the back. You
may also wish to imagine how your lower back touches the back of
the chair or the surface of your mattress. [If the patient finds this to be
a difficult task to accomplish, I highly recommend that he or she re-
turn to the first preliminary exercise and repeat the section which fo-
cuses on tensing and relaxing the muscles of the back.] As you
remain focused on the muscles of your lower back, simply repeat
with each exhalation: “Relaxed and calm.” Repeat this for a slightly
longer period, such as five to eight breaths.
The final segment of this exercise concerns making mental contact
with the lower extremities. It is best to perform this in several small
steps. Begin by focusing on the muscles of your right thigh, from your
hip to the knee. If it helps, imagine that you are looking at the muscles
of your right thigh with your eyes closed. With each exhalation,
silently repeat: “Relaxed and calm.” After three to five exhalations,
move to the muscles of the lower leg, from your knee to your ankle,
and then pay attention to the muscles of your right foot. With each
exhalation repeat: “Relaxed and calm.” Now concentrate on your en-
tire leg and repeat: “Relaxed and calm.”
Now shift your attention to your left leg, from your hip to your
knee. With each exhalation repeat: “Relaxed and calm.” After three to
five breaths, move to the muscles of your lower leg, from your knee to
your ankle and then all the way down to your foot. Silently repeat:
“Relaxed and calm” for three to five breaths. Then focus on your en-
tire leg and repeat: “Relaxed and calm.”
Upon completing this segment, allow your body and mind to be
calm and peaceful. When you are ready to end the exercise, take a few
deep breaths, stretch out your arms and your legs, and get up very
gently. You need to repeat this exercise for several days before begin-
ning the standard autogenic exercises. If you find yourself having dif-
ficulties with this second exercise, especially after practicing for two
or three times, return to the first exercise for a day or two and then re-
peat this exercise once again. There is no reason to rush the process.
Take your time and you will reap the benefits of your patience and
perseverance.
Make sure to complete the Pain Checklist [Form B] at the end of
the exercise. After practicing the preliminary exercises for several
days, I highly recommend that you review the data that you have been
collecting before and after each relaxation session. In time, you will
have a reliable and useful record of your progress. Also, I urge you to
use these every time you practice the standard autogenic exercises.
REMARKS
At times people with chronic pain and fibromyalgia wonder with

great frustration why suddenly they have a bad day after several ex-
ceptionally good days. By asking my patients to develop a process of
active data collection regarding their pain, sleep, and other activities,
I have been able to help them solve some of the mysteries regarding
the fluctuations in their symptoms. Remember, the more they learn
about their condition, the easier it is to predict certain (but not all)
changes in symptoms, which should help them develop better strate-
gies for coping. This approach should considerably help mitigate the
sense of helplessness that is often a concomitant of any chronic con-
dition. As it was pointed out, the two checklists (Appendix A) can be
most helpful in assisting patients gain a better understanding of their
pain levels, especially before and after each training session. They
can also be used effectively for gathering outcome data at the end of
the treatment period. Another useful instrument, the Autogenic Prog-
ress Index, appears in Appendix B. This form is especially helpful for
clinicians to determine when the patient is ready to move to the sub-
sequent standard exercise.
Chapter 8
The First Standard Exercise:

Heaviness
The first standard autogenic exercise, and for that matter all subse-
quent exercises, needs to begin by reducing environmental stimulation
to the lowest possible level. Lights may be dimmed, sources of noise
should be effectively eliminated, and finally the patient needs to posi-
tion himself or herself in a fashion that is restful and as free of discom-
fort as possible. Review the specific autogenic postures as described in
Chapter 6 and help the patient choose a position that is most agreeable.
Also, inform the patient that the best time for practicing these exercises
is usually twenty minutes after lunch or dinner and before retiring for
the evening. An important point to remember is that autogenic exer-
cises should never be abruptly ended (indeed, it is inadvisable to con-
clude any form of relaxation or meditative exercises in a sudden
fashion). The body requires a period of adjustment to the physiological
changes that have occurred as a result of the practice of autogenic exer-
cises. Patients may experience dizziness, disorientation, and light-
headedness if they attempt to stand up quickly at the end of the
exercise. Although such sensations usually do not last very long, they
can be most disturbing. These experiences can be avoided by conclud-
ing each exercise slowly and by allowing the body enough time to
make the appropriate adjustments. A brief set of guidelines for each
training session is provided in Table 8.1. These guidelines need to be
reviewed by the therapist at the beginning of each session.
INTRODUCING THE FIRST EXERCISE
The first standard exercise focuses on inducing a pleasant sensa-

tion of heaviness in the extremities, which is similar to that experi-
enced shortly before falling asleep. Patients are instructed to repeat
95
TABLE 8.1. A Review of Guidelines for Autogenic Training Sessions
1. Prior to each training session, the therapist needs to describe, in depth, the ra-
tionale and the goals for that session. It is imperative that the patient feels com-
fortable with his or her understanding of this rationale.
2. The therapist needs to emphasize the importance of “no volition” or “passive
concentration” to the fullest at the beginning of each and every session.
3. The therapist may suggest appropriate images for each exercise such as,
“Imagine a cool breeze brushing against your forehead as you repeat the fore-
head cooling formula.” Although the patient is not required to use the same vi-
sual suggestions, such images may serve as a tentative guideline. They will
also help the patient differentiate between effective versus ineffective or harm-
ful images (e.g., holding a warm cup of coffee while repeating, “My right arm is
warm,” instead of immersing one’s hand in boiling water).
4. Each session needs to be intentionally terminated by having the patient flex the
arms, take a deep breath, and open the eyes.
5. The patient needs to feel quite comfortable with each exercise before moving
on to a more advanced exercise. That is to say, if the patient does not experi-
ence the sensation of heaviness in the arms, do not introduce the warmth for-
mula. The use of the Autogenic Progress Index (Appendix B) is highly
recommended. The index needs to be completed at the end of each training
session. The clinical data generated by this form can be most helpful in deter-
mining when the patient is ready to transition to the next standard exercise.
6. Emphasize at the onset of the training that it is the patient’s responsibility to
practice the assigned exercise at least twice a day for approximately fifteen
minutes. Little progress can be made without commitment to daily practice.
7. Encourage the patient to express his or her feelings, thoughts, and sensations
at the end of each training session. The therapist’s openness and
nonjudgmental attitude toward exploring such experiences, whether mental or
physical, serves as a crucial facet of the training.
specific formulas over and over while maintaining a casual or a non-

goal-oriented attitude. That is to say, they should refrain from forcing
themselves to make anything happen. Remember, forcing oneself to
experience a particular sensation is most likely to result in the experi-
ence of greater levels of tension and stress, the exact opposite of what
we are trying to achieve. The next step is to help patients passively
imagine or visualize what it would feel like if their arms and legs
were becoming heavier. Green and Green (1977) describe this pro-
cess by stating that “One just tells the body what to do, usually by vi-
sualizing the desired state, then detaches from the situation—steps
aside, gets out of the way, so to speak—and allows the body to do it”
(p. 54). Although one may find it tempting to think of carrying a
The First Standard Exercise: Heaviness 97
heavy object to induce the sensation of heaviness, or imagining that

one’s arms are leadlike, this is against Schultz’s advice. He empha-
sizes that the sensation of heaviness should be a normal, agreeable,
and comfortable one—very similar to what is experienced before
falling asleep—which is akin to a profound experience of muscle re-
laxation. For example, patients may be asked to ponder, “My right
arm is comfortably, or pleasantly, heavy.” After a period of consistent
daily practice, thinking or repeating the formula several times is suf-
ficient to bring about the experience of muscle relaxation in the arms
and the legs.
As discussed earlier, patients should be instructed that they can
substantially facilitate the experience of this sensation by ensuring
that their arms, shoulders, legs, and lower back are well supported.
They need to be sure that no undue stress is placed upon these areas
during the exercise. If they attempt to perform these exercises while
holding their muscles in a rigid manner, it is quite likely that they will
not be able to achieve the desired effects. That is why the therapeutic,
autogenic postures described in Chapter 6 are so crucial in achieving
the desired effects.
Prior to the start of the first exercise, I highly recommend review-
ing the pre-exercise checklist (see Table 8.2) to ensure that the appro-
priate physical or environmental preparations have been made. Next,
attention needs to be paid to “the appropriate mind-set” before re-
peating the specific formulas for this exercise. One of the most con-
cise statements that captures the process of autogenic exercises is
eloquently stated by Norris and Fahrion (1984, p. 235). You may
wish to place a bookmark here and return to this paragraph at the be-
ginning of each training session.
TABLE 8.2. The Pre-Exercise Checklist
1. Complete the Autogenic Pain (or Tension) Checklist (Form A)

2. Reduce environmental stimulation and assume a training posture
3. Passive concentration on the formulas and physical sensations
4. Make mental contact with specific body parts
5. Repeat the autogenic formulas
6. Daily practice (Reminder)
At this point you will be given some autogenic training phrases,

and I want you to [silently] say each phrase over and over to your-
self. First, your attitude as you do this is quite important. This is
the kind of thing where the more you try to relax, the less it will
happen. So the best approach is to have the intention to relax, but
to remain detached about your actual results. Since everyone can
learn voluntary control of these processes, it is only a matter of
time until you do, therefore you can afford to be detached about
the results. Second, saying the phrases is good because it keeps
them in mind, but it is not enough. The part of the brain that con-
trols these processes, the limbic system, doesn’t understand lan-
guage well, so it is important to translate the content of the phrase
into some kind of image. One of the phrases is “My hands are
heavy and warm.” If you can imagine what it would feel like if
your hands did feel heavy or if they did feel warm, that helps to
bring about the changes that we are looking for. Or use a visual
image: Imagine that you are lying at the beach in the sun, or that
you are holding your hands over a campfire. Whatever works for
you as a relaxing image or a warmth-inducing image is the thing
to use, but the imaging itself is important. Finally, if you simply
trust your body to do what you are visualizing it as doing, then
you will discover that it will.
In some of the original literature on autogenic training, Schultz

(1932) suggested that as a way of promoting a deeper state of rest and
relaxation special background formulas may be used. In some of the
earlier manuals, he had his patients repeat the word “tranquility”
(ruhe in German) between each formula. In later English publica-
tions, the formula “I am at peace” was introduced. I encouraged my
patients to use this formula or the word tranquility throughout each
exercise, as suggested in the following training sequence.
Again, it is highly recommended that prior to starting the auto-
genic exercises, patients familiarize themselves with the preliminary
exercises that were described in Chapter 7. These exercises will help
them gain much greater momentum while practicing the standard ex-
ercises. As mentioned before, the preliminary exercises need not be
practiced for long. Perhaps four or five times should be sufficient to
master the desired effects of achieving mental contact with specific
body parts.
Each formula used during the first training session is to be repeated

for approximately two minutes. The choice of beginning the training
with the right or the left arm solely depends on the patient’s handed-
ness. That is, if he or she is right-handed it is best to make mental con-
tact initially with the right arm and hand. Throughout the years of
using autogenic training with chronic pain patients, especially those
suffering from fibromyalgia, I have come to realize that certain addi-
tional formulas can be most helpful in reducing pain and discomfort.
These additional formulas (marked with an asterisk) are consistent
with those developed by Schultz and actually seem to enhance the
training process significantly. For example, I have observed that during
the pre-sleep state (similar to the autogenic state), the muscles of the
jaw tend to relax. By repeating a formula that suggests a heavy and re-
laxed jaw, this process of entering a deeper state of relaxation is accel-
erated. Also, since many fibromyalgia patients tend to suffer from
temporomandibular joint disorder (TMJD), the focus on a relaxed jaw
can be most helpful in reducing pain and discomfort as well as making
them aware of the tendency to possibly grit or grind their teeth due to
extremely tense muscles. I have also included additional formulas for
reducing muscle tension in the shoulders and the lower back.
THE BRIEF EXERCISE
Remind patients to complete the Pain Checklist, Form A, prior to

beginning each session.* The following instructions may be read to
the patient:
You are now ready to begin the first exercise. For the first two or three
sessions, I recommend a shorter form of the exercise to be followed by
the extended exercise. [Please make sure that you have reviewed with
the patients the requirements for the effective practice of autogenic train-
ing as described in Chapter 7.] Remember that it is quite likely that from
time to time you will be distracted by a passing thought. As soon as you
become aware of this, gently guide yourself back to the formula and the
specific body part that is the focus of your attention.
*If the patient is being treated for stress management, the Tension Checklists should
be substituted for the Pain Checklists.
Now assume a comfortable position. Close your eyes and take a

few deep breaths. If you find it difficult to take deep and comfortable
breaths, you may want to shrug your shoulders as you inhale and
slowly drop your shoulders. Let go of the tension as you exhale.
Then, gently and silently begin repeating to yourself the following
formulas. Each formula needs to be repeated five to seven times.
• I am at peace.
• My right arm is heavy.
• My left arm is heavy.
• I am at peace.
• My right leg is heavy.
• My left leg is heavy.
• I am at peace.
• My entire body is heavy and relaxed.
• I am at peace.
To conclude the exercise, take a deep breath and as you exhale

gently flex your arms and open your eyes. Give yourself a few min-
utes before standing up. Repeat this exercise for three consecutive
days. [Remind the patient to complete the Pain Checklist, Form B, af-
ter each exercise.]
THE EXTENDED EXERCISE
Approximately four days after practicing the brief exercise, pa-

tients may begin the extended exercise. Remind patients to complete
the Pain Checklist, Form A, prior to beginning each session.
After assuming your desired, comfortable posture, take a few deep
breaths and begin repeating the following formulas, each for five to
seven times.
• I am quiet and relaxed.

• I am at peace.
Now begin making mental contact with various body parts as you
repeat the following formulas.
• My right (left) arm is heavy.

• I am at peace.
• My left (right) arm is heavy.
• I am at peace.
• Both arms are heavy.
• I am at peace.
• My shoulders are heavy.*
• I am at peace.
• My jaw is heavy.*
• I am at peace.
• My right (left) leg is heavy.
• I am at peace.
• My left (right) leg is heavy.
• I am at peace.
• Both legs are heavy.
• I am at peace.
• My lower back is heavy.*
• My entire body is comfortably relaxed.
• I am at peace.
Now take a deep breath, and as you exhale, stretch out your arms
and your legs several times, and then open your eyes. [Make sure that
the patient completes the Pain Checklist, Form B, upon finishing the
exercise.]
Green and Green (1977) suggest saying the following affirmation
as a way of concluding the exercise: “I feel life and energy flowing
through my arms, my legs, and my whole body. The energy makes
me feel light and alive” (p. 338). A statement such as this may be used
to more smoothly make the transition from the autogenic state to an
alert state.
It is of significant therapeutic value that patients express their ex-
periences and observations at the end of each exercise. A record of
such experiences can, in time, provide valuable insight into ways of
improving the benefits of the training. Each exercise needs to be prac-
ticed twice a day for approximately ten to fifteen minutes. It is not un-
common for certain stress-related symptoms such as headaches and
gastrointestinal distress to spontaneously disappear during the prac-
tice of the heaviness exercise. However, it may take some time for the
*This is not a standard formula.
corrective properties of autogenic training, in terms of reestablishing

a systemic state of balance and healing, to occur.
Before proceeding to the next standard formula, it is imperative
that patients have been able to comfortably experience a “volition-
free” sensation of heaviness in your extremities. For optimum results,
it is best to practice each standard exercise twice a day for at least a
week. Also, it is not prudent to move to a more advanced exercise
without achieving the particular sensations suggested in each and ev-
ery phase of the training. Before moving to the second standard exer-
cise, which focuses on the sensation of warmth, patients need to be
able to comfortably experience the sensation of heaviness in their
arms and legs. Once this has been achieved after several practice ses-
sions, they are ready to proceed to the next exercise.
COMMON DIFFICULTIES
WITH THE FIRST STANDARD EXERCISE
The most common difficulty with the first exercise (experienced by

roughly 20 percent of patients) concerns the inability to stay focused.
Distractions are quite common during the practice of any relaxation
or meditative exercise. Patients need to be reassured that as long as
they adhere to the requirements for the correct practice of the auto-
genic exercises, it is only a matter of time before they can effectively
overcome intrusive thoughts. However, there are several clinical
guidelines that practitioners should keep in mind when patients re-
port persistent, intrusive, and distressing thoughts. In my opinion, the
most effective method of stopping distressing thoughts is to talk
about them. The training process may need to be put on hold, often
briefly, so that the patient may openly discuss the nature of the
thoughts.
Another method of reducing distress from the experience of men-
tal distractions is to initially shorten the length of the exercises, such
as reducing the number of the repetitions to three to five times, so as
to help the patient maintain better concentration. As the ability to
maintain focus increases, the exercises are gradually made longer
with additional repetitions.
For those patients who have difficulty experiencing the heaviness
sensation, my recommendation is to reassure them that with passive
concentration and repetition of the formulas, this will occur in a short

while. In rare cases, when patients continue to show difficulty with
the experience of heaviness in the extremities, it may be helpful to
have them hold a small weight in each hand prior to starting the exer-
cise. They should merely focus on what it feels like to experience the
sensation of heaviness as they hold the weights.
An ingenious idea proposed by Thomas (1967) is to have the pa-
tient perform the exercise in a bathtub and briefly and gently lift up
his or her arm while repeating the heaviness formula. I have found
this method to be of great value even in the most difficult and resistant
cases. This approach needs to be attempted only once for the patient
to make the appropriate connections between the formulas and the
desired sensation of heaviness.
In rare cases, when patients are not adhering to the principle of
passive concentration, they may report a tense, aching sensation in
their arms while practicing the first standard exercise. They should be
instructed “not to try to make anything happen” and pay close atten-
tion to the requirements for the exercises.
Finally, if the patient reports difficulty with making mental contact
with a specific body part during the repetition a formula, I highly rec-
ommend spending more time with the preliminary exercises which
were discussed in Chapter 7. Also, prior to a training (exercise) ses-
sion some patients find it helpful to lightly touch the body part with
which they cannot make mental contact.
CASE EXAMPLE
MJ is a forty-two-year-old woman who was diagnosed with fibro-

myalgia pain syndrome approximately two years ago. In addition to
some of the common symptoms of fibromyalgia, MJ was particularly
distressed because of pain and constant discomfort in her forearms.
At times the discomfort was so severe that she could not even slightly
raise her hands and arms to pick up the lightest of objects. On those
“bad” days she was completely dependent on her children for basic
grooming, such as brushing her hair.
She described her arms as being “in constant spasm.” Prior to the
treatment, her forearm surface electromyographic activity (EMG)
showed to be well above average. After familiarizing herself with the
preliminary exercises (Chapter 7), MJ was trained in the first auto-

genic exercise for approximately three weeks. She initially found it
difficult to make mental contact with her arms because she wanted to
avoid her painful arms at all costs. This tendency to avoid focusing on
her arms was apparently contributing to the worsening of her symp-
toms. By practicing the heaviness exercise she began experiencing a
comfortable sensation of heaviness in her arms. Later in the treatment
when additional exercises were introduced, MJ gained greater strength
in both arms and the constant, aching sensation began to disappear.
Even on the bad days she was able to use the exercises effectively to
manage her pain and discomfort.
Chapter 9
The Second Standard Exercise:

Warmth
Almost invariably, many fibromyalgia, chronic fatigue, and chronic

pain patients complain of cold hands and feet. Some wear heavy
socks to bed to avoid giving their spouse an unpleasant experience
should the spouse rub against the patient’s icy feet. The experience of
cold extremities is a common occurrence when a source of threat is
perceived. One of the body’s methods of protecting against loss of
blood in case of injury or laceration is to constrict the blood vessels in
the periphery. The human body is equipped to cope effectively with
such blood volume changes in the short term, however, this form of
vasoconstriction can, in time, place undo demands on the various or-
gans of the body, especially the heart. In some people, the experience
of prolonged pain can result in a state of chronic vasoconstriction,
which may bring about additional complications.
The second standard autogenic exercise focuses on generating
warmth in the extremities, and it is a critical stage in the process of
training because it paves the way for some of the more advanced ex-
ercises (especially the fifth exercise, and the additional formulas for
pain control and sleep enhancement). The resultant vasodilation from
the practice of this exercise may be viewed as a shift from a “stress”
to a “relaxation” state influenced by changes in the hypothalamic-ad-
renal cortex axis, a major mechanism involved in the stress-recupera-
tive and recovery response from the experience of stress brought on
by pain, and other sources of demand. As the body moves from an ac-
tivity state (catabolic) into a regeneration mode (anabolic), the blood
vessels tend to dilate and a pleasantly agreeable sensation of warmth
in the arms and the legs is experienced. Initially, such a sensation may
105
be limited to the hands and the arms, but in time the shoulders, legs,
and feet will be affected. During the fifth standard exercise, emphasis
will be placed upon generating warmth in the abdominal region that will
significantly deepen the relaxation state. Please note that it is impera-
tive that prior to moving to the second exercise, patients must be able
to almost effortlessly experience a sensation of heaviness in their
arms and legs after repeating the formulas from the first exercise. It is
inadvisable to initiate the second exercise as long as this objective has
not been achieved.
Long before the advent of antianxiety medications such as Valium,
Xanex, and Ativan, hot baths were used to reduce anxiety and ten-
sion. The second autogenic exercise accomplishes this reduction of
anxiety and tension through the activation of the appropriate centers
in the brain which promote a normalizing effect in the vascular sys-
tem. Indeed, during the practice of this exercise most anxious patients
report the experience of a pleasantly drowsy, tranquil state which is
similar to the feeling experienced after taking a tranquilizer, but with-
out the common side effects. As it will be discussed in the chapter on
sleep (Chapter 16), the sensation of warmth can be used quite effec-
tively as a method of initiating and enhancing sleep. At the same
time, keep in mind that upon concluding the second exercise, patients
need to give themselves some extra time before they stand up and re-
turn to their daily routines. This will help to avoid any unpleasant sen-
sations such as disorientation, or dizziness.
During this second phase, patients are asked to passively repeat
formulas that suggest a sensation of heaviness and warmth in their
extremities. Again it is helpful to consider imagining what it would
be like if they were experiencing a soothing and pleasant sensation of
warmth in the arms and the legs. For example, you may suggest that
patients consider the image of lying on warm sand at the beach on a
sunny day. Ask them to think of their body as a sponge that is slowly
absorbing the heat from the sand. Or you may suggest imagining
what it would be like if they were soaking in a warm bath and were
beginning to gradually experience a soothing sensation of heaviness
and warmth in the arms and legs.
Here it is imperative that certain precautions are observed with re-
gard to the content of imagery. First, ask the patients to refrain from
forcing themselves to think of the beach or the warm bath. They need
The Second Standard Exercise: Warmth 107
to be instructed not to limit themselves to these specific images and

should feel free to use whatever comes naturally. For instance, one
may think of holding a warm cup of tea between the hands and then
allow the warmth to travel from the hands into the arms and shoul-
ders. Second, and this is a most critical requirement, these images
should never include touching something that is hot. Such images can
result in a rapid instead of a gradual increase in peripheral vasodilation
and may cause uncomfortable sensations. Always suggest sensations
that promote a pleasant sensation of warmth, preferably a sensation that
is experienced gradually.
Once in a while, and in extremely rare cases, some people may find
it difficult to experience the sensation of warmth in their arms. I rec-
ommend two methods for making progress in such cases. First, I
highly recommend using temperature biofeedback in conjunction
with the warmth formula for brief periods of time and with eyes open.
This is to reinforce the slightest change in hand temperature. How-
ever, if a temperature unit or even a hand thermometer is not avail-
able, or the person finds it difficult to benefit from this approach,
another option based on an observation of Schultz and Luthe may be
used. They recommend that it may be helpful to have the individual
immerse his or her arms in a basin of warm (not hot) water prior to the
practice of the warmth formulas (Schultz and Luthe, 1959). I have
found this to be of particular benefit for achieving the objective of the
second exercise. In my experience, even in the most refractory cases,
this technique seems to work.
The actual training sequence in the second standard exercise is
similar to the first exercise.
THE WARMTH EXERCISE

beginning each session. The following instructions may be read to the
patient:
After quieting yourself for a few minutes, gently close your eyes
and silently begin repeating the following formulas:

• I am at peace.
• My right arm is heavy and warm.
• I am at peace.
• My left arm is heavy and warm.
• I am at peace.
• My shoulders are heavy and warm.
• I am at peace.
• My jaw is heavy and warm.
• I am at peace.
• My right leg is heavy and warm.
• I am at peace.
• My left leg is heavy and warm.
• I am at peace.
• My right foot is heavy and warm.
• I am at peace.
• My left foot is heavy and warm.
• I am at peace.
• My lower back is heavy and warm.
• I am at peace.
To conclude the exercise, take a deep breath and as you exhale
gently flex and open your arms. Give yourself a few minutes before
standing up. [Make sure that the patient completes the Pain Checklist,
Form B, upon finishing the exercise.]
The induction of a sensation of warmth in the extremities may
bring about a profound sensation of relaxation and even sleepiness.
Therefore, it is of clinical importance that patients are fully awakened
upon the completion of the exercise. Often, stretching the arms and
the legs and opening the eyes is sufficient for this purpose. Taking
several deep breaths may actually expedite the process.
Before concluding this section, it may be helpful to consider an in-
teresting case report that appeared in the second volume of Autogenic
Therapy, (Luthe and Schultz, 1969a), which deals with the many
medical applications of this approach. This case effectively portrays
how the warmth exercise can be a life-saving tool.
A well-known sportsman who had learned autogenic training
for the purpose of improving his performance was caught by an
avalanche. He and his companions were buried under the snow

in below 30 degrees Centigrade temperatures and had to stay
motionless for several hours until they were rescued. The ad-
vanced trainee applied the autogenic approach and focused on
warmth in nose, fingers, toes and ears in rotation. He was the
only person who escaped without frostbite or any other injury
from the cold. (Luthe and Schultz, 1969a, p. 80)
While I hope that those suffering from chronic pain and fibro-
myalgia will not find themselves in the predicament of these sports-
men, the inspiration from this report should help those who avoid the
frozen food section in a grocery store because of severe sensitivity to
cold. I have instructed many of my patients with extremely cold
hands to practice portions of the warmth exercise before entering the
grocery store or prior to leaving home on a cold day. These patients
report rewarding applications of this and other standard exercises.
COMMON DIFFICULTIES
WITH THE SECOND STANDARD EXERCISE
If the heaviness exercises are performed adequately, the experience

of warmth should come almost naturally during the practice of the sec-
ond standard exercise. Since the second exercise requires closer atten-
tion to the principle of passive concentration, patients need to be
reminded to resist any tendency to make their hands warmer. Any such
attempts will inevitably result in paradoxical experiences, such as
cooling of the hands and the arms or a sudden experience of pain and
tension with or without stiffness. Although such experiences are rare
and occur on those occasions when the patient is trying to warm the ex-
tremities, it is prudent to end the exercise if distressing sensations are
experienced for more than a few minutes. The most effective method
of intervention is to have the patient flex the arms, take a deep breath,
and open the eyes during exhalation. This is as effective as the cancel-
lation method used during hypnosis. As mentioned earlier, it is impor-
tant to process the sessions by having the patient discuss his or her
experiences and sensations, especially on those occasions when persis-
tent distressing sensations begin to emerge.
To assist patients who have difficulty experiencing the sensation of

warmth, I highly recommend Schultz’s warm water immersion which
was discussed earlier. This technique is especially of great help to pa-
tients with very cold extremities. Simply have them immerse one arm
in warm water for a few minutes and pay attention to the soothing sen-
sation of warmth. I have used this technique effectively with patients
who have very cold feet and find it difficult to focus on a sensation of
warmth in their feet. The period of immersion needs to be brief and
very focused. To maintain the necessary focus, the practitioner should
instruct the patient to pay close attention to his or her arm as it is be-
ing slowly immersed in warm water, especially as the sensation of
warmth begins to spread (this is best done with the eyes closed for
greater focus).
Finally, a brief and sudden decrease in the temperature of the ex-
tremities may suggest an autogenic discharge. This should not be in-
terfered with as long as the sensations are brief and not distressing.
Patients need to be instructed to simply observe such passing sensations
and allow the nervous system to make the appropriate adjustments.
As a rule, I always have the patient’s nondominant hand monitored via
a thermistor during each training session, even when the patient is not
provided with direct feedback. Such information can be very helpful
in assessing the process of training and to make the necessary adjust-
ments when needed.
CASE EXAMPLE
One of the first patients that I treated with autogenic training was a
very distressed bartender who was about to lose his job because of a
loss of sensation in his hands several hours after touching ice-filled
glasses and cold drinks. On several occasions, he had actually cut his
hands without being aware of it. Medical tests had ruled out any neu-
rological causes for this, although it had been suggested that he was
suffering from a mild to moderate form of Raynaud’s syndrome.
(Some fibromyalgia patients may also experience this condition.) Af-
ter four weeks of autogenic training with emphasis on the second ex-
ercise, the patient was able to gradually raise the temperature of his
hands. The immersion technique was used in two occasions to help
him more easily move to the second standard exercise. He was also
provided with a bulb thermometer which he used to monitor his im-
provement before and after each exercise session at home. His steady
improvements were highly motivating, and in time he was able to
generate a soothing sensation of warmth in his hands with his eyes
open. He reported to me that he often repeated some of the warmth
formulas to himself while at work and was able to effectively combat
his condition with confidence.
Chapter 10
The Third Standard Exercise: Heart
After the first two standard exercises have been fully mastered, pa-
tients will be ready to begin the third standard exercise, which fo-
cuses on the activity of the heart. This exercise requires further
preparation and it is important that some additional time is spent to
familiarize patients with some of its intricacies. For example, to gain
a better sense of cardiac activity, a specific resting posture plays a
crucial role. As shown in Photo 6.4 (Chapter 6), this may be achieved
by assuming the supine position with the right hand comfortably
placed on the chest region, directly above the heart. Schultz and
Luthe (1959) suggest that most of us need to “discover” our heart. It
is noteworthy that most people initially state that they have little or no
awareness of their cardiac activity. However, this type of awareness
can easily be achieved by observing certain conditions. Again, spe-
cial attention is placed on assuming a particular training posture. As
seen in Photo 6.4, note that the right arm is slightly elevated to make
the positioning of the hand on the chest as comfortable as possible.
The head and the shoulders are elevated by the use of a soft pillow. As
it was mentioned earlier, patients must refrain from trying to force
anything to happen. Passive concentration plays a more crucial role
in this exercise than in the previous sessions. In time, such therapeu-
tic awareness will be achieved quite effortlessly and naturally. Before
instructing patients to make mental contact with their heart during the
exercise, it is best to allow them a few minutes to explore and experi-
ence the heart rate prior to repeating the new formula. The next step is
to begin repeating the formulas from the first two standard exercises
and then introduce the new formulas:
113
• My heartbeat is calm.
• My heartbeat is calm and regular.
• My heartbeat is calm and strong.
Note that these formulas are not about consciously changing the
heartbeat or making the heartbeat faster or slower. Instead, the focus
is on a calm and regular heartbeat, which is a hallmark of a relaxed
and tranquil state. This sets the stage for the natural self-regulatory
mechanisms to take over and bring about the necessary changes that
are health enhancing. What is most important in this exercise is the
patient’s ability to be patient and allow the gradual experience of the
sensations of relaxation.
Throughout the years, I have noticed that soon after engaging in the
third exercise many patients begin to enter a profound state of tranquil-
ity and psychophysical calmness which resulted in falling asleep. A
large majority of my patients have stated that they begin to truly appre-
ciate the experience of a deepening in their ability to relax after they
complete the third exercise. This is a natural juncture in the training
where a tendency for anxiety and panic attacks can be significantly and
effectively improved. Such improvements may occur spontaneously
and without a need to specifically treat such symptoms.
Although usually we may not be aware of the activity of the heart,
we constantly maintain a subconscious, yet profound, contact with
this organ as its activity can either arouse us or gently put us to sleep.
Schwartz (1989) reported that “self-attention” to cardiac activity in a
relaxed fashion can, by itself, initiate a self-regulatory process with
potential “localized healing.” That is to say, passive attention to the
activity of the heart may bring about a state of greater order and bal-
ance within the body. Also, symptomatic relief from mild forms of
mitral valve prolapse, which are often quite distressing (and reported
by a number of fibromyalgia patients), can be effectively achieved
within a matter of weeks with the use of the cardiac formulas. How-
ever, if a patient is suffering from any form of cardiac condition, it is
imperative that he or she consults a physician prior to engaging in this
exercise. Although in a clinical setting I have never observed any
complications with this exercise, certain necessary precautions should
be observed so that the progress in this training is not hindered.
Jencks (1979) further supports these observations and experiences:
The Third Standard Exercise: Heart 115
“Occasionally one meets with the opinion that the observation of the
rhythm of the heart leads to undue concern with the heart. The author
has never observed this, nor noticed any reference to it in the autogenic
training literature. In fact, the contrary seems to occur” (p. 28).
To begin this exercise, please observe the requirements that were
described previously. Assist patients in finding a comfortable posi-
tion while lying on their back. Next, have them place their right hand
on the chest and allow a few minutes to comfortably make mental
contact with the heart.
THE HEART EXERCISE

patient:
When you feel ready, gently close your eyes and silently begin re-
peating the following formulas:

• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• My left leg is heavy and warm
• I am at peace.
• I am at peace.
• I am at peace.

• I am at peace.
Now begin paying attention to your heart in a passive and relaxed

way. After a few moments, repeat to yourself:
• I am at peace.
• I am at peace.
• I am at peace.
• My heartbeat is calm and steady.*
• I am at peace.
• I am at peace.
Now allow yourself to be calm and quiet and enjoy the feeling of to-
tal relaxation and tranquility. When you feel ready, take a deep breath,
flex and then stretch out your arms and open your eyes. You may also
wish to gently stretch out your legs. Give yourself a few moments be-
fore you sit up from the supine position. [Make sure that the patient
completes the Pain Checklist, Form B, upon finishing the exercise.]
COMMON DIFFICULTIES
WITH THE THIRD STANDARD EXERCISE
The third standard exercise may initially appear as difficult to

teach and to learn. Although the main focus of the first two phases of
training was on inducing heaviness and warmth in the extremities, the
third exercise focuses on an internal organ which may present diffi-
culties as far the requirement of “making mental contact” is con-
cerned. The specific training posture developed for the third exercise
should make the task of “discovering” the activity of the heart much
easier. Most patients require assuming the position with the right
hand placed on the chest cavity only for a few sessions before they
can perform the exercise in a horizontal or a reclined position without
the hand placement.
The Third Standard Exercise: Heart 117
The practitioner needs to instruct the patient to take his or her time
and develop a sense for the cardiac rhythm prior to initiating this
phase of treatment. As it was stated, it is critical in this exercise to em-
phasize to the patient that the objective is not to reduce or to increase
the activity of the heart. The need for emphasizing passive concentra-
tion on the activity of the heart becomes even more crucial during the
third exercise. Jencks (1979) reported that by having patients focus
on the rhythm of the heart, such passive concentration may be main-
tained more effectively. Some patients may initially report an in-
crease in their cardiac activity immediately after repeating the heart
formulas. They should be instructed not to interfere with this phe-
nomenon and should continue to passively repeat the formula. When
necessary, patients may repeat the background formula, “I am at
peace,” more frequently before repeating, “My heartbeat is calm and
steady.” Again, if distressing sensations persist, the exercise may be
concluded by flexing the arm, taking a deep breath, and opening the
eyes. Luthe reported that in those rare cases when patients present
with difficulties regarding heart formulas, it is probable that they
have certain fears about their cardiac health, possibly due to their
medical history (in Lindemann, 1973). In addition to appropriate
screening prior to commencing the training, it may be helpful to ex-
plore patients’ fears and concerns.
As stated earlier in this chapter, when performed correctly, the re-
laxing, tranquilizing, and rejuvenating effects of this exercise can be
so profound that many patients report a spontaneous improvement in
their sleep. Also, home practice of the exercises begins to improve,
especially in terms of a deepening of relaxation and a reduction in the
overall experience of pain and tension. This phase of training is so
important because of its therapeutic benefits that Luthe (1977) ad-
vises against moving to the next exercise until the objectives of the
third exercise have been achieved.
CASE EXAMPLE
JA was a healthy, active woman prior to a motor vehicle accident

which resulted in the development of symptoms of fibromyalgia (post-
traumatic). As she was beginning to learn ways of coping with her
pain and discomfort, she began experiencing dizziness and paniclike

experiences. The symptoms became so disturbing that eventually she
was referred to a cardiologist for further evaluation. JA was diag-
nosed with mitral valve prolapse and was asked to learn stress man-
agement strategies to cope with her symptoms. Also, she was in-
structed to follow a diet free of stimulants.
I began working with JA for over a month before she was ready to
begin the third standard autogenic exercise. An entire session was de-
voted to helping her discover her cardiac activity. This was done in
brief five-minute segments with time for reporting subjective experi-
ences and encouraging passive concentration. Although initially she
was apprehensive about paying attention to her heartbeat, her anxiety
began to subside and disappear after she began following the instruc-
tions and practicing the exercise on a regular basis. Her cardiologist,
who referred her to me, was also pleased with her improvements and
gradually began reducing her medications. JA often remarked that
“the heart tape” was her favorite—her “audio tranquilizer.” Similar
sentiments are often expressed by patients after mastering the third
standard exercise.
Chapter 11
The Fourth Standard Exercise:

Respiration
Efficient and effective breathing is perhaps one of the most central

elements in enhancing self-regulation. The old adage that “breath is
life” is indeed an accurate one and may be expanded to “ineffective
breathing can interfere with healthy living.” That is, although respira-
tion is an automatic process, we can, at will, affect the rate and the
depth of our breathing. Jencks (1977) observed that most children use
their diaphragm quite well to allow their respiration to maintain an op-
timum level of inhalation and exhalation. Most adults on the other
hand, and especially those suffering from chronic pain, tend to breathe
in a shallow, controlled fashion. Many authors have suggested that
conditions such as panic and anxiety attacks, chest and upper back
pain, and muscle tension may be attributed to improper breathing.
Smith (1989) convincingly reminds us that “breathing is the only basic
physiological process that is both voluntary and involuntary” (p. 113).
Without a doubt, breathing exercises are the most commonly
taught techniques in stress management courses. One of the most
well-known, popular methods of relaxation, Hatha Yoga, combines
deep breathing with stretching of specific muscle groups. Diaphrag-
matic breathing is another prevalent relaxation procedure through which
people are taught to enhance their process of respiration by focusing
on abdominal instead of chest breathing. If used ineffectively and too
forcefully, this technique can actually have paradoxical effects, which
may cause greater tension, stress, and possible symptoms such as diz-
ziness, numbness in the hands, and other disturbing sensations.
119
The autogenic approach for improving proper respiration is quite

different from other, more popular techniques. Without active inter-
vention or volitions, patients report improved respiration through the
use of specific autogenic formulas. However, I am by no means
against the use of various breathing techniques and strongly feel that
they can be used quite effectively in clinical settings and at home. If
patients are familiar with such techniques, they may wish to use them
during the preliminary exercises but I advise against using them dur-
ing an autogenic session. This concern was also shared by Schultz
and Luthe (1969) who made the following remark: “In trainees with
healthy respiratory systems, training difficulties are relatively rare
and are reported chiefly by trainees who have learned and practiced
some sort of respiratory exercises before starting autogenic therapy.
These trainees find it exceptionally difficult to remain passive and to
let ‘it’ (the respiratory system) work without interference” (p. 100).
It is quite likely that by the time patients are ready to begin the
fourth standard autogenic exercise, they have already become aware
of a deepening in their breathing and the concomitant experience of
more profound calmness. As with the previous exercises, patients
need to be reminded that any conscious attempt at changing their
breathing should be avoided at all costs. Any active form of interven-
tion may result in a greater level of arousal, which is likely to make
respiration more irregular. Impress upon them the importance of fol-
lowing the instructions for the previous exercises and allowing the in-
born physiological mechanisms to make the appropriate transition
into a more pronounced state of recuperation regeneration. This state
is further reinforced and enhanced during the respiration exercise.
Similar to the heart exercise, patients are asked to bring a greater level
of passive concentration or passive attention to an inward focus on
the internal rhythms of the body, which in this case is breathing
rhythm. Jencks (1977) suggested spending a few minutes prior to the
exercise observing the respiratory activity in terms of inhalations, ex-
halations, and changes in movements in chest and abdominal areas.
The formulas for this session, which are to be repeated after the
heaviness, warmth, and heart formulas, are described below.
• My breathing is calm.
• My breathing is calm and regular.
The Fourth Standard Exercise: Respiration 121
• I breathe comfortably and naturally.*

• It breathes me.
Schultz’s original formula for this exercise was: “It breathes me.”
Although it is difficult to do justice to the profound philosophical and
psychophysiological wisdom of such a phrase in a few paragraphs, it is
also true that most people have difficulty comprehending and/or relat-
ing to this formula. Therefore some explanation is in order. The word
“it” embodies a critical concept in understanding the process of self-
regulation. At any moment, there are innumerable bodily events taking
place that are not even remotely perceived by our conscious awareness.
The body’s physiological mechanisms are self-supporting and do not
require active participation to maintain their functioning. In reality we
can interfere with these mechanisms by trying to force changes in their
activities, a process that is antithetical to the autogenic philosophy. “It”
denotes those unconscious physiological mechanisms that allow the
body to maintain its state of balance. In other words, “it knows” how to
breathe, how to maintain proper temperature, how to promote effective
digestion, etc. Awake or asleep, “it” brings the necessary changes that
are needed for survival. Unfortunately, due to exposure to traumatic
events and long-term stressors such as pain, this innate mechanism of
self-regulation (it) can become derailed and lose its effectiveness in
generating an internal state of balance and harmony.
Prior to using the key formula, “it breathes me,” at least initially, an
appropriate substitution may be a formula that suggests calm and reg-
ular breathing. Ultimately, the most salient point of this exercise is
that we often interfere with natural breathing, which by itself can in-
duce undue stress. The brain’s own self-regulatory mechanisms are
quite capable of maintaining optimal breathing without requiring any
assistance from the conscious mind: “it” knows how to breathe and
how to do so effectively and efficiently, as it does while we sleep. By
entering the autogenic state through the repetition of such formulas,
the body’s innate abilities are summoned to make the appropriate and
necessary psychophysiological adjustments.
Because the respiration formulas are preceded by the heart exer-
cise, a supine position is highly recommended, at least initially, to
achieve the optimum level of relaxation from this exercise.
THE RESPIRATION EXERCISE

patient:
When you are ready, gently close your eyes and silently begin re-
peating the following formulas.

• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
Now pay attention to your cardiac activity in a passive and relaxed

fashion:
• I am at peace.
• I am at peace.
• I am at peace.
Now passively begin paying attention to your breathing. After a

brief pause begin repeating to yourself:
• I am at peace.
• I am at peace.
• I breathe comfortably and naturally.
• I am at peace.
• It breathes me.
• I am at peace.
• I am at peace.
After repeating the last formula, allow yourself to be calm and

quiet for a few minutes. Then after taking a deep breath, flex your
arms and slowly open your eyes. Again, please keep in mind that you
should not get up too quickly in order to avoid any uncomfortable
sensations. [Make sure that the patient completes the Pain Checklist,
Form B, upon finishing the exercise.]
A generalized sensation of warmth, warmth all over the body, is of-

ten experienced during the practice of this exercise. Muscle tension
tends to dissolve considerably and it is only prudent to make sure that
the patient is comfortable and ready to assume a sitting and/or a
standing position. If necessary, have the patient gently stretch out his
or her arms and legs several times before standing up.
COMMON DIFFICULTIES
WITH THE FOURTH STANDARD EXERCISE
The most challenging difficulty with the breathing exercise is pre-

sented by those who attempt to breathe in a particular fashion, such as
“doing” diaphragmatic breathing. These tendencies should be resisted
and the patient should be instructed not to use previous training in other
forms of breathing while performing the fourth standard exercise. As
soon as some patients begin repeating the formula, “My breathing is
calm and regular,” they tend to consciously slow their breathing, or use
their abdomen “to do the breathing.” Helping them to become aware of
these tendencies is very critical at this stage of training.
Unless the patient fully understands the objective of this exercise,
it is best to use examples, emphasize passive concentration, and per-
form brief experiments with the new formulas, until he or she can
perform the exercise in a volition-free state. In difficult cases, to
“undo” contradictory instructions and habits, it is important to pro-
ceed slowly by shortening the training sessions and emphasizing the
need for passive concentration. The importance of fully emphasizing
the meaning and the implications of the formula, “It breathes me,”
cannot possibly be overemphasized, especially when persistent diffi-
culties and/or resistance are encountered.
By the time they reach the fourth standard exercise, the majority of
patients have already become aware of a pleasant deepening in their
breathing. Once they learn not to force this process, they will soon be-
come aware of the profoundly quieting effect of this exercise. A com-
mon observation that is often made by chronic pain patients after
training in the fourth exercise is that their shoulders feel much more
relaxed. An almost total disappearance of cognitive and somatic anx-
iety is another typical observation during and after each practice ses-
sion.
CASE EXAMPLE
One of the most difficult cases of posttraumatic nightmare disorder

I treated involved a young woman who had developed a phobia of not
being able to breathe while asleep. The patient, KS, was in a severe
motor vehicle accident, which in addition to physical injury resulted
in her experiencing frequent and very disturbing nightmares. To help
her sleep better, one of her physicians had prescribed an antianxiety
medication. Although such medications can be quite helpful for a
brief period of time, KS began experiencing even more distress and
anxiety because she could not wake from the nightmares. Shortly af-
ter that, she became preoccupied with the thought that she was not
going to be able to breathe while asleep. This further complicated her
recovery because she avoided falling asleep until the early hours of
the morning when she would pass out. During the fourth autogenic
training session, I spent some time describing to her the importance
of the formula “it breathes me.” I indicated to her that her body was
capable of breathing quite effectively without her assistance. Soon “it
breathes me” became one of her favorite formulas and she learned to
use it to gradually control some of her symptoms of anxiety. In time,
with the use of autogenic exercises and an advanced autogenic tech-
nique known as autogenic abreaction, the disturbing dreams ceased
altogether (see Sadigh, 1999).
Chapter 12
The Fifth Standard Exercise:

Abdominal Warmth
Long before the birth of autogenic training, it was common practice

in hospitals to apply a hot compress to the abdominal region to bring
about a calming and tranquilizing effect, especially to promote sleep
and to reduce anxiety. In the same fashion, passive concentration on
generating warmth in the abdominal region further enhances the body’s
self-regulatory mechanisms already initiated through the first four
standard exercises. One additional point is to be considered prior to
training in the fifth formula. Those who suffer from severe gastrointes-
tinal symptoms, especially bleeding ulcers, may not be appropriate
candidates for this phase of training. An increase in the circulation of
the abdominal region may actually aggravate such conditions. In such
cases, the fifth exercise may be postponed until the condition is brought
under control (through medication, changes in diet, etc.) and is no lon-
ger in an acute state. In severe cases of gastrointestinal (GI) disorders,
the exercise may be abandoned altogether and the patient may proceed
to the sixth standard exercise, which focuses on cooling the forehead.
There have been reports of minor abdominal pain that completely dis-
appeared after the use of the fifth exercise because of its profoundly re-
laxing properties, but it should not be attempted by those who are
suffering from a bleeding ulcer or ulcerative colitis.
Diabetes is another condition to keep in mind prior to training in
the fifth standard exercise. It has been postulated that the induction of
warmth in the abdominal cavity may affect carbohydrate metabo-
lism, which will consequently cause changes in insulin levels. Under
the close supervision of an endocrinologist, and with the use of the
fifth exercise, I have been able to help a number of diabetics lower
127
their doses of injected insulin. Although the benefits of the effective

use of this exercise can be quite rewarding for the patient, I recom-
mend caution and a slower pace for the training. Above all, make sure
that the patient is under close medical supervision (as discussed in
Chapter 5, patients with endocrinologic symptoms and disorders
need to be treated only in collaboration with a treating physician).
Schultz and Luthe (1959) reported the following case, which, al-
though rare, may serve as an important example of the potency of
these exercises.
A young diabetic who required relatively high quantities of in-

sulin and who mastered the standard exercises was asked to con-
tinue autogenic training by emphasizing the development of
warmth in the upper regions of the abdomen. After effective ex-
ercises had been practiced frequently, the patient began to suffer
from hypoglycemic shocks because he continued injecting the
same amount of insulin as he took before. After taking 20 units
less, the patient felt well even though he was not too careful
about dietary indiscretions. (p. 71)
As with the third standard exercise (heart), we are going to move

from the periphery (the arms and the legs) toward the internal organs.
The main focus of the fifth exercise is not to bring about a sensation
of warmth on the surface of the abdominal region or the skin. The
main objective is to improve circulation and to promote a pleasant
sensation of heat in a deep region of the upper abdominal cavity re-
ferred to as the solar plexus. This region of the abdomen sits behind
the stomach and immediately in front of the spine, and contains an in-
tricate interweaving of fibers of the autonomic nervous system. Thus,
this region plays a crucial role in the regulation of the activities of
many of the internal organs, especially in terms of the blood supply to
the stomach, liver, kidneys, pancreas, and many other organs. Figure
12.1 shows the location of the solar plexus. It is important that the pa-
tient has some sense of the location of this region prior to practicing
the appropriate formula.
Traditionally, the main formula for this exercise has been, “My so-
lar plexus is warm.” However, I have found it equally effective to
have patients repeat to themselves, “My abdomen is warm.” Again,
as long as they know that by “abdomen” we mean a deeper region of
The Fifth Standard Exercise: Abdominal Warmth 129
FIGURE 12.1. The Location of the Solar Plexus
the upper abdominal cavity and not the surface area, either formula
should work quite effectively in accomplishing the goal of this exer-
cise. In the original autogenic writings, Schultz and Luthe (1959)
suggested that as a method of improving circulation in the abdominal
region, therapists might want to hold a hand between the tip of the
sternum and the umbilicus and have the patient focus on the sensation
of warmth and allow it to gradually move deeper into this region.
They also suggested that, at least initially, while the patient was fo-
cusing on the heat from the therapist’s hand, the following formula
should be repeated: “Heat rays are warming the depth of my abdo-
men.” This was to be followed by the formula “My solar plexus is
warm.”
As indicated in Chapter 7, I have developed a new postural posi-

tion for this exercise which significantly enhances the effectiveness
of the formula. This position is considerably similar to the one rec-
ommended for the heart exercise with two exceptions. First, the hand
is placed (very lightly) on the center of the upper abdominal region,
right below the breastbone. Second, one may use either hand as long
as the position of the arm is as comfortable as possible. It is important
that patients experiment with this position until they discover the po-
sition that places the least amount of stress and tension on the abdo-
men and the arm. I recommend repositioning a pillow under the arm
until this objective is achieved.
Another way of facilitating the effects of this exercise is to com-
bine the formula with the following image: “Imagine drinking a
warm liquid and follow the warmth as it moves down the esophagus,
enters the abdomen, and a soothing heat begins to concentrate in the
solar plexus region.” If it is possible for the patient to visualize the
heat penetrating the abdominal region and especially concentrating
behind the stomach and in the front of the spine, he or she will
quickly notice a profound state of relaxation affecting the entire
body. As stated earlier, many may actually fall asleep during the prac-
tice of this exercise because of its tranquilizing properties. To remedy
this, an additional formula is suggested to be repeated at the begin-
ning of the fifth exercise: “I remain peacefully alert during the exer-
cise.”
Given the potent properties of this exercise, and the concern that
some patients might have about irritable bowel syndrome and/or oc-
casional stomach upset, a gradual process of increasing the sensation
of warmth in the abdominal region is advised. This can be accom-
plished by attenuating or diluting the key formula. For example, I
suggest that all patients initially repeat to themselves: “My abdomen
(solar plexus) is slightly warm.” Then the formula is replaced with
“My abdomen (solar plexus) is pleasantly warm.” And finally, “My
abdomen (solar plexus) is warm.” This approach quite effectively
safeguards the patient against any unpleasant sensations that may be
brought on by a sudden increase in circulation. Again I must empha-
size that if a patient is currently suffering from an actively bleeding
ulcer or a severe case of colitis, this exercise should be postponed un-
til the condition has been treated medically and has been brought un-
der control.
At this juncture in the training, the many benefits of the fifth exer-
cise can also make it easier to address musculoskeletal pain. This is
usually the time when I introduce some additional formulas for pain
management and coping. Luthe and Schultz (1969a) reported a spon-
taneous reduction in pain while focusing on an agreeable sensation of
warmth both in the periphery and in the abdominal region. Most
chronic pain patients suffer from diffuse and widespread pain that
seems to be, at least partially, the result of vasoconstriction and
ischemia. Once this condition is counteracted through the practice of
the standard exercises, beneficial effects such as a reduction in pain
and stiffness may be observed. Hence, I have found it extremely use-
ful to include an additional formula (not a standard one) for reducing
pain which emphasizes the healing qualities of an increase in blood
flow in certain muscle groups. The new formula, “Warmth dissolves
the pain,” can be used quite effectively to bring about soothing relief
in painful and cramped muscles.
The basic instruction for the use of this formula is rather simple, al-
though attention to certain specific details is required. First, to maxi-
mize the benefits of this formula, patients should not use it until they
have reached the end of the fifth exercise, which sets the stage for the
perfect opportunity to work on reducing pain. Second, the formula
needs to be used initially in a specific way. That is to say, patients need
to use it to affect pain and discomfort in a specific muscle group, for in-
stance, the muscles of the right leg and not both legs simultaneously.
Patients need to focus on one area before moving to another. Finally,
if patients are experiencing a severe inflammatory condition, such as
inflammation of the knees, they should wait until the condition is
brought under control before using the pain formula.
Once the patients have been provided with the above instructions
and precautions, they are ready to begin the fifth autogenic exercise.
Again, a supine position is advised with specific attention placed
upon the position of the hand (in the upper abdominal region, see
Photo 6.5 in Chapter 6). It is best not to use the abdominal exercise
shortly after eating a meal. To effectively complete the training se-
quence, at least twenty minutes needs to be allocated to the exercise.
THE ABDOMINAL WARMTH EXERCISE
Remind the patients to complete the Pain Checklist, Form A, prior

to beginning each session. The following instructions may be read to
the patient:
When you are ready, gently close your eyes and then silently begin
repeating the following formulas:
• I remain peacefully alert during the exercise. [optional]

• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
• I am at peace.
Now passively pay attention to your cardiac activity, and then be-
gin repeating the following formulas:
• I am at peace.
• I am at peace.
• I am at peace.
Now passively pay attention to your breathing.
• I am at peace.
• I am at peace.
• I am at peace.
• It breathes me.
• I am at peace.
Now pay attention to your upper abdominal cavity, behind the

stomach and in front of the spine. Then begin repeating:
• My abdomen is slightly warm.

• I am at peace.
• My abdomen is pleasantly warm.
• I am at peace.
• My abdomen is warm.
Now pay attention to a specific muscle group that may be painful

or extremely tense and then begin repeating to yourself:
• Warmth dissolves the pain.

• I am at peace.
At this point you may also wish to shift your attention to another mus-
cle group and begin repeating the formula “warmth dissolves the pain.”

• I am at peace.
Allow yourself a few minutes before ending the session. When you
are ready, take a deep breath and as you exhale, flex your arms,
stretch out your legs, and open your eyes. Please sit up very slowly.
[Make sure that the patient completes the Pain Checklist, Form B,
upon finishing the exercise.]
Schultz and Luthe (1969), and Luthe (1970a) reported that approx-
imatley 50 percent of their trainees became quite sleepy during the
practice of the fifth exercise, and roughly 10 percent actually fell
asleep at the conclusion of the session. Therefore, it is quite possible
that the first few times patients use this exercise they may experience
a profound state of tranquility or may actually fall asleep. Because of
this, during home practice, the use of an alarm clock is not recom-
mended as its jarring sound may counteract the beneficial effects of
the training. Patients may wish to have someone gently check on
them twenty minutes into the exercise, or, if possible, set their alarm
clock to play soft music. The use of an additional formula recom-
mended by Lindemann (1973) may be quite helpful to avoid falling
asleep. This formula is repeated approximately five to seven times
prior to starting the training sequence: After closing the eyes, the pa-
tient may repeat, “I stay free and fresh while training” or “I remain
calm and alert during the exercise.”
COMMON DIFFICULTIES
WITH THE FIFTH STANDARD EXERCISE
Allow me to emphasize once again that patients need to follow cer-

tain precautions before engaging in this exercise. Patients initially are
advised to use the attenuated forms of the formulas, such as, “My ab-
domen is slightly warm,” in order to avoid any unpleasant sensations.
With that said, there are usually few problems reported with the prac-
tice of this exercise. The special posture developed for the fifth stan-
dard exercise is sufficient to help gradually induce a pleasant
sensation of warmth in the abdominal cavity. However, patients need
to be reminded of resting the right hand very lightly on the upper ab-
dominal region, and only during the first few sessions of training. If
the posture or the visualization of drinking a warm liquid do not facil-
itate the process of warming the abdomen, it may be helpful to have
the patient actually drink some warm liquid and focus on his or her
sensations as the liquid enters the abdomen.
Benign abdominal sounds usually noticed during the practice of
this exercise need to be ignored. It is helpful to mention this to pa-
tients before commencing this exercise so that they do not try to sud-
denly tense their abdomen because of such sounds, since such action
results in counterproductive consequences.
Patients also need to be made aware of the tranquilizing nature of
this exercise and should be instructed to give themselves ample time
to end the exercise appropriately, especially while practicing at home.
Some patients report that their muscles become soft and rubbery.
They should be cautioned not to stand up too quickly after ending the
exercise. Arms may need to be flexed several times to effectively con-
clude the training session.
CASE EXAMPLE
CG was a forty-nine-year-old security guard who developed se-

vere pain in his lower back due to an injury at work. After approxi-
mately three months of grappling with his back pain, CG began
experiencing some of the distinct symptoms of fibromyalgia pain
syndrome. At times his muscles were so tight that he could hardly
stand or sit. His sleep deteriorated significantly and he began experi-
encing frequent anxiety attacks and became clinically depressed. Ini-
tially, a combination of strong pain medications and anxiolytic agents
were used to help him cope. Eventually, hydrotherapy became one of
his favorite ways of reducing tension in his lower back, but unfortu-
nately the effects were short-lived. During his multidisciplinary treat-
ments he was introduced to autogenic training. He began using the
techniques after doing his stretches in the morning, every afternoon,
and before going to bed at night.
CG particularly liked the fifth exercise and was able to achieve a
high level of relaxation while practicing it. He also noticed that he
could effectively use the fifth exercise to more quickly initiate sleep.
When his sleep was disrupted due to pain, he could induce the sensa-
tions of heaviness and warmth in his extremities by simply repeating,
“My abdomen is pleasantly warm,” and “Warmth makes me sleepy.”
In time, he was able to use several additional formulas to bring relief
to his aching back. He described this exercise as a combination of “a
tranquilizer and a pain pill without the grogginess.”
Chapter 13
The Sixth Standard Exercise:

Forehead Cooling
Another method of inducing a tranquilizing and drowsy state is by

applying a cool compress to the forehead. A similar sensation is also
perceived shortly before falling asleep. Also, people often notice that
during active problem solving and intense mental activity the fore-
head tends to feel much warmer. Conversely, as one quiets his or her
mind, a naturally pleasant, cooling sensation over the region of the
forehead is experienced. Self-generated reduction in the temperature
of the head is the last standard autogenic exercise—an exercise that is
also extremely potent and effective. When a sensation of warmth in
the trunk is combined with a cooling sensation in the forehead, a pro-
foundly soothing state of relaxation is achieved. Each step of the
autogenic training to this point has focused on achieving a psycho-
physiological state in which effective self-regulation and recovery
from pain-induced stress can be attained. The sixth standard exercise
further enhances this process.
Given the highly tranquilizing nature of this exercise, certain pre-
cautions need to be observed. First, to avoid any uncomfortable ef-
fects from the use of this exercise, patients need to play close
attention to the images they use to promote the cooling sensation in
the forehead region. For example, they must refrain from using any
images that suggest the visualization of ice or snow, a cold liquid, or a
cold can of soda on the forehead (Luthe, 1979). They should be en-
couraged to focus on a cooling sensation and not on a cold one. Im-
ages suggesting “a cool breeze,” “a cool hand placed gently on the
forehead,” or “a cool cloth on the forehead” can be highly effective.
In other words, the cooling sensation must be pleasant and agreeable
137
and conducive to bringing on a tranquil state. Second, this exercise is

best practiced while lying down, at least initially. The possible, but
brief, negative effects that one may experience are dizziness or possi-
bly disorientation. However, this can be effectively circumvented by
using the horizontal posture and by getting up very slowly at the end
of the training session. By following these simple instructions, pa-
tients can benefit from the many positive effects of the forehead cool-
ing exercise.
Up to this point, the previous exercises have extensively focused
on generating a sensation of warmth in the extremities and the ab-
dominal regions. Therefore, the initial attempt at focusing on a cool-
ing sensation over the region of the forehead may be difficult. For this
reason, I suggest that prior to the first session of practicing the sixth
autogenic exercise, it may help to perform a simple sensory enhance-
ment technique. For example, a few minutes before starting the exer-
cise, instruct the patients to wet one hand in cool (not cold) water and
place it on the forehead. Ask them to focus on the cooling sensation
and repeat this two to three times, until they know what to look for
during the session. Or, on a cool and pleasant day, you may want to
ask them to open the windows and allow a gentle cool breeze to blow
over their face. Then have them recall this sensation during the prac-
tice of the exercise. It is important for patients to be reassured that it
may take days or weeks before they actually experience the cooling
of the forehead while repeating the new formula. Emphasize patience
and again, at all costs, make sure they avoid thinking about some-
thing cold to accelerate the process of training.
Consistent with the other exercises reviewed thus far, after repeat-
ing the formulas from the previous exercise, patients are asked to
make mental contact with the forehead and simply begin repeating
the following standard formula:
• My forehead is cool.
I have found it very helpful to have patients initially use an attenu-

ated form of this formula such as:
• My forehead is slightly cool.

• My forehead is comfortably cool.
• My forehead is pleasantly cool.
The Sixth Standard Exercise: Forehead Cooling 139
In time, as patients begin to master these exercises to their fullest

potential, they simply need to repeat one or two formulas or even
think about a cooling sensation in the forehead region to activate the
entire autogenic process. Until then, it is best to take time and follow
a more gradual approach.
After reviewing the pre-exercise checklist and assuming a hori-
zontal position, the training sequence may commence.
THE FOREHEAD COOLING EXERCISE

patient:
When you are ready, gently close your eyes and then silently begin
repeating the following formulas:

• I am at peace.
• I am at peace.
• I am at peace.
• Both arms are heavy and warm.
• I am at peace.
• I am at peace.
• My jaw is heavy and relaxed.
• I am at peace.
• I am at peace.
• I am at peace.
• Both legs are heavy and warm.
• I am at peace.
• I am at peace.
• I am at peace.
• Both feet are heavy and warm.
Now passively pay attention to your cardiac activity and then begin
repeating:
• I am at peace.
• I am at peace.
• I am at peace.
Now passively pay attention to your breathing and then begin re-
peating:
• I am at peace.
• I am at peace.
• I am at peace.
• It breathes me.
• I am at peace.
Now begin paying attention to your upper abdominal cavity and

then begin repeating:
• My abdomen is slightly warm.

• I am at peace.
• I am at peace.
• My abdomen is warm.
You may now wish to pay attention to a specific muscle group and
begin repeating the following formula for pain control.
• Warmth dissolves the pain.

• I am at peace.
Give yourself a few moments prior to moving to the forehead cool-

ing formula. You may wish to think of a pleasantly cool breeze brush-
ing against (only) your forehead. Then begin repeating:
• My forehead is slightly cool.

• I am at peace.
• I am at peace.
• My forehead is cool.
• I am at peace.
• I am at peace.
Give yourself a few minutes to enjoy the soothing sensation of re-

laxation. You may initially find yourself resisting the need to con-
clude the exercise, however, if you need to get up and go somewhere,
please make sure that you end the exercises after taking a few deep
breaths, flexing your arms, stretching out your legs, and opening your
eyes. After opening your eyes, wait for a few moments before sitting
up. Then give yourself two to three minutes before standing up.
[Make sure that the patient completes the Pain Checklist, Form B,
upon finishing the exercise.]
COMMON DIFFICULTIES
WITH THE SIXTH STANDARD EXERCISE
By the time patients are ready to begin the sixth standard exercise,
they have spent weeks or even months practicing the other five pre-
ceding exercises, with the sensation of warmth playing a critical role
in their structure. Hence, some difficulty may be experienced in shift-
ing one’s attention from soothing warmth to a pleasantly cooling sen-
sation in the region of the forehead. To avoid unnecessary frustration, it
is best to dampen the forehead with cool water while exploring the
forehead cooling objective of the exercise. Allowing a cool breeze to
blow on one’s face may be another effective method of achieving the
same objective. Such exploratory techniques need to be attempted
only a few times prior to performing the exercise. Side effects such as
dizziness and disorientation usually disappear quickly at the conclu-

sion of the exercise. They can be avoided by using attenuated ver-
sions of the formula for forehead cooling, such as, “My forehead is
slightly cool,” and “ My forehead is pleasantly cool.”
As mentioned before, patients should initially perform the sixth
standard exercise while in a horizontal position, thus assisting the
nervous system to more easily make the necessary adjustments. The
cooling of the forehead, when achieved slowly and cautiously, can be
a very pleasant exercise with profoundly tranquilizing effects.
CASE EXAMPLE
KW is an executive secretary who works at a respected firm and

enjoys her work very much. She works hard and is highly respected
by her employers. Two years ago, KW was in a terrible motor vehicle
accident in which the emergency crew required over an hour to rescue
her from the wreckage of her car. Fortunately, her physical injuries
were not that serious and she was able to recover relatively quickly.
However, KW began developing some disturbing symptoms of post-
traumatic stress disorder. Perhaps one of her worst symptoms mani-
fested itself in her need to have fresh air blown on her face. Although
this was a manageable problem at home, it was extremely difficult to
cope with at work. She related to me that while at home, if she be-
came anxious she needed only to open one of the windows and spend
a few minutes cooling her head. This, however, was not an easy op-
tion at work. She worked on the tenth floor of a building with sealed
windows, and her only choice was to go all the way to the first floor to
cope with her need for air. (In time she discovered an open window in
the maintenance area on the second floor which she referred to as her
“rescue window.”) Another factor that complicated the situation was
that at such times, she became very claustrophobic and could not ride
the elevator to the first floor. Going down the steps was also problem-
atic because of her aching back and sensitive knees (the result of the
accident). She always carried tranquilizers with her which, unfortu-
nately, had certain side effects and interfered with her work.
KW learned to quickly put some of the autogenic formulas into use
to cope with her symptoms of pain and posttraumatic stress disorder.
However, the sixth standard exercise became her favorite because it

allowed her to experience a tranquil state of relaxation very similar to
putting her head out the window. She now quite effectively practices
the forehead cooling exercise while sitting up. Because of her resolve
and determination, she continues to make good and steady progress.
Chapter 14
Advanced Autogenic Training
Approximately six to eight weeks after beginning the first standard

autogenic exercise and after the patients have achieved the basic ob-
jectives of each of the exercises (sensations of heaviness and warmth
in the extremities, etc.), they may be ready for some of the more ab-
breviated forms of autogenic training, which will be discussed next.
This chapter also includes some of the more advanced formulas that
build upon the initial training that was explored previously. There-
fore, before using the information explored in this chapter, patients
are urged to first master the standard exercises.
After some steady practice with the autogenic exercises, most peo-
ple will be able to activate the chain of responses that are generated in
the standard exercises in a matter of minutes. This will be especially
helpful just before or shortly after exposure to stressful situations. In
a way, the advanced exercises may be viewed as a method of rapid re-
fueling and replenishing of one’s psychophysiological resources. Al-
though it is imperative to continue to use the standard exercises for a
while, benefits of the training can be summoned quickly and effec-
tively with the repetition of some key formulas. In time it is possible
to initiate sleep much more quickly with the use of these advanced
formulas. These formulas can also be helpful in reducing the number
of sleep interruptions that most chronic pain and fibromyalgia pa-
tients experience on a regular basis. Mothers with young children of-
ten report that they appreciate more restful sleep while using some of
the advanced formulas.
Many of my patients, especially those who suffer from chronic fa-
tigue syndrome, have noted that instead of taking ineffective naps,
they have been able to replenish themselves and gain more physical
145
and cognitive stamina by using these (advanced) autogenic formulas.

Some of these patients have reported that ten to fifteen minutes of
autogenic training is more “energizing” than an hour or more of nap-
ping, which often causes them to feel more tired and “groggy.” I usu-
ally instruct patients to refuel as often as possible so that they can
enjoy more of their daily activities. Despite these helpful techniques,
the advanced formulas are not a replacement for a good night’s rest
and the regular practice of the standard exercises.
One of the of the main focuses of these advanced exercises is to
more quickly generalize the sensation of heaviness and warmth.
Instead of repeating six or eight formulas, one can learn to achieve
the same results by repeating only three or four formulas.
THE ABBREVIATED SEQUENCE

FOR REPLENISHMENT
During the practice of the abbreviated exercises, while one can use
the specific postures that were described before, it is best to learn an
additional sitting posture that can promote almost an instant state of
relaxation, especially in the upper body portion (see Photo 14.1). Pa-
tients are instructed to sit in a comfortable position with their feet
firmly placed on the floor. Next, they are asked to close their eyes,
and after taking a deep breath, exhale and allow the arms to go limp.
The head is gently dropped down and is maintained in this position
while comfortable breathing is encouraged. The image of this relax-
ing position is known as the “rag doll” posture.
For this posture, patients may be provided with the following in-
structions:
Imagine that a thread is attached to the top of your head that holds
your head and neck in an upright position. Your shoulders are slightly
pulled back and your arms are comfortably hanging next to your
trunk. Next, imagine that the thread is cut and at once your body falls
into a limp and tension-free position. To further enhance the relaxing
effects of this posture, slightly lift up your right arm, inhale slowly,
and as you exhale let your arm become totally limp. Imagine that
your arm is so limp that at this point it would be very difficult for you
Advanced Autogenic Training 147
PHOTO 14.1. The “Rag Doll” Sitting Position
to move it. Now slightly lift up your left arm, inhale slowly, and as
you exhale let your arm become totally limp. Now gently lift up your
shoulders, inhale deeply, and as you exhale let your shoulders drop
totally and allow them to assume a very limp and relaxed position.
Breathe comfortably and naturally. When you are ready, begin re-
peating to yourself the following formulas:
• I am at peace.
• My arms (as you naturally inhale) are heavy and warm. (as you
naturally exhale)
• My neck and shoulders (inhale) are heavy and warm. (exhale)
• Both legs (inhale) are heavy and warm. (exhale)
• My breathing (inhale) is effortless. (exhale)
• It breathes me.
• My entire body (inhale) is limp and relaxed. (exhale)
• My mind is quiet.
• My body is healing.
• I am at peace.
You may end the exercise by taking a deep breath, shaking your
arms and repeating to yourself: “ I feel refreshed and energized. My
body is strong and full of vitality.”
As with the previous exercises, make sure that patients get up very
slowly during the abbreviated exercise as well. This abbreviated exer-
cise can be done in less than ten minutes. Patients should make room
in their schedule to practice it at least three times a day. They are also
instructed not to wait until they are totally exhausted to practice these
or any other techniques. It is better to have brief “refueling” sessions
throughout the day than to expect full rejuvenation in the evening. As
it will be discussed in Chapter 16 on sleep, total exhaustion actually
prevents people from entering the deeper, recuperative stages of
sleep. Therefore, it is best to include autogenic training into one’s
daily routine on a regular basis.
THE USE OF THE ORGAN-SPECIFIC FORMULAS
Once the standard autogenic exercises have been fully mastered,

additional formulas may be introduced to affect the functioning of
particular body systems. These formulas are called “organ specific”
and their effects are consistent with those observed during the regular
training. The introduction of these additional formulas has been
found to be useful, especially when greater attention is needed for
normalization of a specific organ, for example the lungs or the gastro-
intestinal tract. As with the previous formulas, patients should be
cautioned not to change the wording of the formulas to achieve par-
ticular results. These formulas emerged from years of research and
observation and their effects have been examined in numerous studies.
Some of the organ-specific formulas are shown in Table 14.1. They
are usually introduced toward the end of a training session after the
sensations of heaviness and warmth have been effectively estab-
lished. Some of the following formulas were adapted from the work
of Schultz and Luthe (1969, p. 177). Additional formulas are based
on my own research. Patients should use these formulas with care and
after they have been medically examined for the possible underlying
causes of their condition. Prior to repeating each formula, it is imper-
TABLE 14.1. Organ-Specific Formulas
Symptoms and Conditions Organ-Specific Formulas

1. Constipation My lower abdomen is warm.*
My pelvis is warm and relaxed.*
2. Mild asthma My chest is comfortably warm.**
Breathing is effortless.
3. Heart palpitations My heartbeat is calm and easy.*
I am relaxed and at ease.
4. Hypertension My forehead is agreeably cool.*
My feet are warm.
5. Premenstrual cramps My abdomen is calm and warm.
Cramps are calm and easy.
6. Raynaud’s syndrome My fingers are warm.*
The tips of my fingers are warm and relaxed.
7. Muscle pain Warmth dissolves the pain.
My pain is dissolving.
8. Insomnia It sleeps me.
Warmth makes me sleepy.*
9. Tingling and paresthesia My nerves function properly.
10. Restless legs My legs are warm and smooth.
Warmth dissolves the tension.
My legs are warm and tension free.
11. Hemorrhoids My anus is heavy.*
My anus is cool.*
My bowels move smoothly.
12. TMJ My jaw is heavy and relaxed.
*From Schultz and Luthe (1959)

**Not to be used during an asthma attack
ative that mental contact is made with the specific organs. For exam-
ple, for muscle pain in the right leg, one needs to make sure that
mental contact is made with the leg prior to repeating the formula:
“Warmth dissolves the pain.”
THE USE OF THE INTENTIONAL FORMULAS
Up to this point, every formula has been based on bringing about

psychophysiological changes or enhancing the functioning of a cer-
tain physiological system. Although the intentional formulas can be

used in the same manner, their primary purpose is to reinforce
changes in behavior and provide further support for mental and phys-
ical well-being. As one reviews these formulas, it may seem that they
tend to be more like affirmations or helpful suggestions that can make
day-to-day living less stressful. However, these formulas are more
than simple, self-improvement affirmations, and with effective use
they can bring about important changes, especially in patients who
suffer from fibromyalgia and chronic fatigue.
Schultz and Luthe (1969) provide a list of intentional formulas that
are both helpful and interesting. In this section I present only a select
few of their suggestions that pertain to the topic of the treatment at
hand. In clinical practice, I have used only a few intentional formulas
as my work has been more specifically focused on treating psycho-
physiological symptoms. I have also introduced several of my own
formulas with a focus on recovery from chronic conditions.
If practitioners choose to use the intentional formulas in clinical prac-
tice, it is important that they observe the same guidelines that were indi-
cated with the organ-specific formulas. Remember that initially patients
should use these formulas after promoting a sensation of heaviness and
warmth in their extremities by repeating some of the preliminary, stan-
dard formulas. Patients refrain from creating their own formulas to avoid
any paradoxical phenomena that may inadvertently occur during the
treatment, especially when the patient is not under supervision at home.
Table 14.2 summarizes a set of nine intentional formulas. It is important
to note that only one (symptom-focused) intentional formula at a time
should be introduced to promote its assimilation.
THE TECHNIQUE OF AUTOGENIC MEDITATION

Autogenic meditation is a unique method of profoundly enhancing
mind-body integration and may be introduced after the patient has
reached a point where he or she can effortlessly enter the autogenic
state with the repetition of a few formulas. I have reserved this for pa-
tients who, after approximately a year of practice, approach me and
ask if there is more to learn. Others may stay with the standard exer-
cises and benefit from their recuperative properties for many years
without incorporating autogenic meditation into their daily practice.
TABLE 14.2. Intentional Formulas
Symptoms and Conditions Intentional Formula

1. Difficulty swallowing My throat is wide and relaxed.*
Swallowing is easy.
2. Compulsivity I need not be perfect.*
Details do not matter.*
3. Shortness of breath due to anxiety I breathe effortlessly.
I breathe comfortably and naturally.
4. Feeling mentally blocked Thoughts flow freely.
My mind is calm and clear.
5. Restless legs Restless legs do not bother me.
It sleeps me.*
6. Recovery after surgery My body is healing.
I am calm and relaxed.
Recovery comes naturally.
Every day I am stronger.
7. Tremors due to anxiety I am calm and still.
My body is quiet.
8. Ear noises The ringing is fading away.
I need not fight the noise.
9. Mental “fogginess” I think clearly.
I am fresh and alert.**
*From Schultz and Luthe (1969)

**From Lindemann (1973)
Autogenic meditation relies heavily on the use of visual phenom-

ena and the elicitation of certain feelings and concepts in a systematic
fashion to promote a more advanced state of autogenic process. This
process further allows various body systems to achieve their opti-
mum functioning through a process of “unloading” the nervous sys-
tem, which occurs naturally during certain stages of sleep (Luthe,
1973).
There are seven meditative exercises:
1. The automatic or spontaneous visualization of colors

2. The visualization of suggested colors
3. The visualization of a definable or concrete objects
4. The visualization of certain concepts
5. The experience of a state of feeling
6. Visualization of other people

7. The insight meditation, in which answers to certain questions
are explored
Since more detailed explorations of the meditative exercises are

beyond the scope of this book, I will only address the processes in-
volved in the first four meditative states. It is my clinical opinion that
meditative exercises five, six, and seven should not be attempted
without psychotherapeutic support. These exercises may elicit feel-
ings and images that will require exploration and clinical interpreta-
tion. Therefore, I will only briefly review these in this section.
Again, the introduction of the meditation is contingent upon the total
command over the practice of the standard exercises. Passive concentra-
tion plays an even more crucial role here, and if it is not mastered, one
should not attempt these advanced techniques. The duration of practice
is another important element to keep in mind, as in time it may be re-
quired to maintain a state of passive concentration from a few minutes
up to an hour. In other words, the exercises should not be rushed.
MEDITATIVE EXERCISE 1:
AUTOMATIC OR SPONTANEOUS
VISUALIZATION OF COLORS
The main objective of the first meditative exercise is to promote

the spontaneous emergence of fixed colors in the entire visual field.
During the practice of the standard exercises, it is likely that the pa-
tient might have experienced seeing certain “background” colors
from time to time. Here, more direct attention is paid to this visual
phenomenon which may serve as an effective method for further
deepening the autogenic state. Prior to beginning the first meditative
exercise it is imperative to enter the autogenic state by repeating sev-
eral of the key formulas.
The following abbreviated sequence may be used for the first med-
itative exercise. Each formula is repeated five to seven times.
• I am at peace.
• My arms are heavy and warm.

• My legs are heavy and warm.
• It breathes me.
• I am at peace.
After repeating these formulas, with eyes closed, patients are

asked to allow colors to spontaneously appear in their visual field.
Initially they may see total darkness or a “grayish” color. Instruct
them to passively observe these colors and emphasize that they
should not force themselves to see any particular colors. Gradually,
particular uniform or static colors will begin to fill the entire visual
field. Once this occurs, they have entered the first meditative state.
Keep in mind that at first it may take a while before spontaneous col-
ors begin to emerge. Patients need to be instructed to be patient and
allow the process to take shape at its own pace. An important obser-
vation by many who have performed this exercise is that in time they
begin to see a specific color that appears each time they enter this
state. This may be viewed as the patient’s “own color” and in time it
may be noticed effortlessly as soon as entering the meditative state. It
may also serve to signal whether he or she has reached this state. Un-
til this personal color begins to appear spontaneously, one should not
look for it. Meanwhile, the ability to maintain a complete level of pas-
sivity is extremely crucial. I recommend staying with the first medita-
tive exercise for several weeks prior to progressing to the next level.
THE VISUALIZATION OF SUGGESTED COLORS
The practice of the second meditative exercise can be significantly

facilitated with the help of a therapist who can instruct the patient to
focus on specific or prescribed colors. However, by following certain
instructions and adhering to them, patients can learn to master this
state quite effectively in a short while and on their own. As with the
first meditative exercise, patients need to begin this exercise by enter-

ing the autogenic state and repeating some of the introductory formu-
las. Please remember that patients should not attempt to enter the
mediative state unless they have achieved the basic objectives of each
of the standard exercises. After they have completed the repetition of
the introductory formulas, I recommend repeating an intentional for-
mula that I have specially developed for the second exercise. This
formula is to be repeated for a minute or two before entering the first
meditative state and is as follows: “Colors appear naturally and
freely.” This formula may also serve as an anchor for those occasions
when patients find themselves drifting or focusing on unrelated
thoughts or sensations. As soon as they become aware of being dis-
tracted, instruct them to simply and passively repeat this formula four
or five times.
The following introductory and intentional formulas need to be re-
peated prior to the second meditative exercise:
• I am at peace.
• It breathes me.
• I am at peace.
• Colors appear naturally and freely.
Prior to starting the second exercise, it is helpful to pre-plan focus-

ing on specific colors. For example, the patient (or as suggested by
the therapist) may choose to visualize the color yellow, and then to
shift to visualizing a different shade of yellow and then work toward
other colors. The patient may use the following helpful suggestion to
make the transition to this exercise much smoother. The therapist
may read the following statement to the patient:
Please follow these instructions very closely to avoid the experi-

ence of undue tension. As you enter the first meditative state and
your color begins to appear, plan to visualize a slightly different

shade of your color. It is best, at least initially, not to try to visu-
alize a color that is totally different. For example, if your sponta-
neous color is dark blue, do not immediately start thinking
about bright red or orange. Consider something such as a
brighter tone of blue or a darker shade of blue or dark purple.
Then gradually begin moving toward visualizing different col-
ors. As a particular color that you have been preplanning begins
to appear, allow it to slowly move from one end of your field of
vision to the other, very much like moving clouds. In a more ad-
vanced state of this exercise, you may begin combining differ-
ent colors (beginning with different shades), allowing them to
merge and move. [I call this the rainbow clouds, which requires
a significant amount of practice.]
It is suggested that the initial practice of the second meditative ex-

ercise be limited to no longer than twenty minutes. With each subse-
quent session, the patient may be encouraged to begin adding five to
ten minutes to each additional practice period, never exceeding a total
of sixty minutes. If performed correctly, the meditative exercises can
be restorative and energizing, very much like having a good night’s
rest.
To fully appreciate the benefits of the second meditative exercise,
patients should be instructed to practice several times a week for at
least a month, and possibly longer, before proceeding to the next
stage of training. It is not prudent to rush the process at any time, or
for any reason. Patients are ready to move to the next exercise when
they can effortlessly visualize a variety of selected (or predetermined
by the therapist) colors with a sense of motion.
THE VISUALIZATION OF DEFINABLE
OR CONCRETE OBJECTS
The third meditative exercise is much more challenging than the

previous two exercises and should be practiced with perseverance.
Any attempt to hasten the process may result in frustration or may
even generate an uncomfortably anxious state. The visualization of

specific, concrete, and definable objects is initially rather difficult.
Although by now patients might have reported experiencing the tran-
sitory appearance of various, shapeless images, the main focus at this
point is to visualize specific objects. It is best to start with simple and
familiar objects. Such objects may include a box, a comb, a cross, or
the Star of David. Objects which evoke a strong emotional response
should be avoided. I recall a patient who began experiencing pro-
found guilt while visualizing a crucifix. She reported that the image
reminded her that the last time she had gone to confession was over a
year ago. She was instructed to choose another image that did not
elicit such emotions and thoughts.
Patients should choose a specific object prior to the first few ses-
sions of practice. The importance of passive concentration cannot be
overemphasized. Again, patients should be instructed not to force
themselves to see anything. After repeating the introductory formulas
and entering the autogenic state, they should allow “their color” to
appear. They may then move to the second meditative state by allow-
ing a cloudlike spectrum of colors to emerge in their field of vision.
Once this point has been reached, they are ready to begin the third
meditative state. Patients may begin this next step by passively think-
ing about the object they had planned to visualize at the beginning of
the exercise. The following instructions may be helpful to share with
the patient:
Allow the object to appear spontaneously. This may take some

time initially, and it is quite likely that the images may appear
briefly and disappear without a trace. Another common occur-
rence is that as soon as you begin seeing the object, it begins to
drift out of your field of vision. Do not become frustrated! As
you continue to maintain a state of passive concentration, the
object of choice will begin to materialize and remain in your
field of vision for a much longer period. In time, other predeter-
mined objects may be visualized with greater ease and sponta-
neity.
For those who have some difficulty with this exercise, I have devel-
oped a simple intentional formula that can be helpful in promoting a
state of passive concentration and in facilitating the process of visual-
ization. In case of persistent distraction, the formula can also be used

as a means of refocusing. After repeating the introductory formulas,
patients may repeat: “Objects appear spontaneously, effortlessly.”
Here is a sequence of formulas that may be used for the third medi-
tative exercise:
• I am at peace.
• It breathes me.
• My forehead is pleasantly warm.
• I am at peace.
• Objects appear spontaneously, effortlessly.
As with the previous exercise, patients need to be instructed to

make sure that they end the exercise session by taking a deep breath
and opening and flexing their arms vigorously. Many patients report
that as they advance in the meditative exercises, they begin to experi-
ence a state of mental clarity and calmness at the conclusion of the pe-
riod of practice. Nevertheless, it is best to encourage them to take
their time and refrain from immediately involving themselves in any
form of physically or mentally arduous activity.
THE VISUALIZATION OF CERTAIN CONCEPTS
The practice of the fourth meditative exercise will require patience

and sensitivity to images, sounds, and possibly certain sensations.
The main focus of the exercise is on visualizing certain concepts such
as beauty, freedom, peace, and tranquility. It is highly recommended
that patients choose a single word (concept) and focus on that partic-
ular word during the entire session. If patients have followed the in-
structions for the previous sessions to the letter, they will find that the
fourth exercise can bring their ability for visualization to new heights.
Several of my patients discovered that they were quite artistically in-
clined as a result of using this and the previous meditative exercises.
It is critical, however, that patients choose concepts that are pleasant
and contain a renewing virtue. At first they may see colors and tones
that depict a certain concept (for example, white for freedom). As the
meditation process deepens, they may actually begin to see flowing,
dreamlike images. Certain sensations may follow these images, and
as long as they are positive in nature they should be allowed to
emerge. For those who have difficulty visualizing these abstract im-
ages, it may be helpful to either visualize the word (the concept) or
have them silently repeat it to themselves several times and then qui-
etly watch what happens. As always, it is of therapeutic value for pa-
tients to make note of the images that reach their consciousness and
observe how they evolve from session to session.
After repeating the sequence of the suggested formulas, patients
may either repeat the concept they wish to visualize or see its letters,
as if appearing in their visual field. They may, for example, see in
bold colors PEACE. Or merely repeat, “Peace . . . (Pause) Peace . . .
(Pause) . . . Peace,” and then allow images to gradually emerge.
The following sequence of formulas may be used for the third
meditative exercise:
• I am at peace.
• It breathes me.
• My forehead is pleasantly warm.
• I am at peace.
(The predetermined concept may be repeated five to seven times at

this juncture prior to its visualization. One may repeat, “Peace . . .
Peace . . . Peace . . .”
The exercise is concluded by taking a deep breath, flexing the arms
and opening the eyes.
About the Next Three Meditative Exercises

As I mentioned earlier, the other three meditative exercises will be
briefly discussed in this section because I strongly feel that they
should be practiced in the presence of a trained psychotherapist. The
fifth exercise, for instance, which focuses on the experience of a se-
lected state of feeling, may require patients to discuss and explore
some feelings that emerge during this exercise. This does not mean
that they should only worry about experiencing negative feelings. For
this exercise to serve its therapeutic purposes, it is extremely helpful
to discuss any emerging feelings at the end of the session. Similarly,
the visualization of a person (Exercise 6) and the insight-seeking
meditation (Exercise 7) require patients to have the opportunity to ex-
plore their thoughts and images with someone who can help define
them. The other four meditative exercises require plenty of time and
attention and should provide ample therapeutic benefits.
THE EXPERIENCE
OF A STATE OF FEELING
During the fifth meditative exercise, patients are instructed to fo-
cus on a selected state of feeling. They may be instructed to passively
imagine a beautiful sunset and experience the feelings promoted by
this visualization. Because feelings and emotions tend to be dynamic,
the patient may spontaneously move from one feeling to another.
During this exercise, images may also change and subsequently feel-
ings may reach a certain intensity without warning. Feelings of ela-
tion and sadness may be experienced from one moment to the next
and these feelings may need to be psychotherapeutically processed.
After some experience with the exercise in a clinical setting, some pa-
tients choose to use it on their own. If this is the case, I recommend
that patients keep a journal to record their experiences.
VISUALIZATION OF OTHER PEOPLE
The sixth meditative exercise is a significant departure from the
other standard and meditative exercises in that its focus is on another
person. In other words, there is a shift from self-focus to other-focus.

The long-term practice of this exercise can bring about changes in the
patient’s attitude toward others, such as deepening compassion and
empathy. However, Schultz and Luthe (1959) wisely recommend that
initially, the patient should focus on “neutral” images of people, for
example the mailman, or the custodial staff. The use of neutral im-
ages is suggested to avoid any sudden experience of emotionally
charged experiences that may dissuade one from further exploring
the benefits of this exercise. Almost invariably, my advanced patients
report that they begin experiencing a state very similar to dreaming as
the images of other people become more clear and unmistakably real.
Patients’ experiences may often range from anger and hostility to
feelings of love, longing, and compassion. Many patients who suffer
from pain due to a motor vehicle accident (especially those with
posttraumatic fibromyalgia), with the subsequent posttraumatic symp-
toms, find this exercise helpful in resolving their feelings toward the
other driver. Because of the potent nature of the imagery that this ex-
ercise tends to evoke, I recommend that it be used only in the pres-
ence of a physician or a therapist who can intervene when necessary.
THE INSIGHT MEDITATION
I refer to this final meditative exercise as the insight meditation to

take away some of the esoteric images and concepts that patients may
conjure up when they hear that they are going to receive “answers”
from their unconscious mind. In a sense, this exercise may be viewed
as a form of free association with a strong potential for psycho-
therapeutic benefits. After entering the autogenic state via the repeti-
tion of the abbreviated formulas, patients are asked to passively focus
on answers to questions such as, “What are my needs?” or “How can I
improve my recovery?” The freely elicited responses should be ex-
plored and therapeutically processed at the end of the session. Some
patients may experience an anxious state during this exercise because
of the “cryptic” nature of their answers. Hence, much like dream in-
terpretation, they may require assistance in deciphering their thoughts
and images.
SOME FINAL THOUGHTS

ABOUT THE MEDITATIVE EXERCISES
An important point about the meditative exercises that cannot be

overemphasized is that they are a natural extension of the standard
exercises. Remember that the main purpose of autogenic training is
to promote a brain-directed state of repair and recuperation. The best
word to capture the training is homeostasis—a state of balance. Basic
autogenic training suggests that exposure to prolonged stress or the
experience of trauma may significantly interfere with the body’s self-
restorative capabilities. With the assistance of specific formulas that
reinforce, enhance, and accentuate a process of repair, we can rees-
tablish a state of mind-body balance which accelerates recovery.
Some of the theoretical concepts of autogenic training, which evolved
into the development of the training formulas, were inspired by ob-
servations regarding the various functions of sleep—its physical,
psychological, and emotional properties (Luthe, 1973). It has been
observed that many of the sensations that occur during a presleep
state are almost completely consistent with the objective of the stan-
dard formulas: muscular relaxation, peripheral warmth, changes in
breathing, etc. As one enters the various stages of sleep, many psy-
chological and physical phenomena continue to occur and each play
an important role. As it will be discussed later, during deep or Stage 4
sleep, certain biochemicals that promote healing are replenished.
During the REM stage of sleep, where much of dreaming takes place,
significant changes in the activities of the higher functions of the
brain with their concomitant cognitive and physiological effects are
made manifest. Pain, stress, worries, and the experience of traumatic
events can significantly interfere with some of the natural processes
that take place during sleep. With the use of the standard autogenic
formulas, patients can be assisted in removing some of the sources of
such interference. The mediative exercises foster various recupera-
tive processes, especially those that occur during dreaming. These
exercises are similar to the unloading phenomenon in which physical,
biochemical, and emotional events that hinder the proper functioning
of the nervous system are gradually removed.
Overall, the standard exercises appear to be a key in promoting the
entire self-recuperative mechanism. The addition of the meditative
exercises, when introduced at the proper time, can further enhance

the functioning of such mechanisms. I have observed, both in myself
and in my patients, very fascinating phenomena as a result of the
practice of the meditations that seem to make access to the standard
exercises faster and significantly more efficient. Some of those who
have been faithfully practicing these techniques report that at one
point, by merely thinking about “their (mentally generated) color,”
they begin to experience an immediate sensation of heaviness and
warmth in their extremities. This is followed by a relaxation of their
cardiac and respiratory activities, a pleasant sensation of warmth in
the abdomen, and finally, the experience of a cooling sensation in the
forehead region. Conversely, a deepening in the autogenic state can
significantly enhance the visualization of the colors and the objects
that are instructed in the meditative exercises.
As indicated earlier in the book, patients ultimately hold the key to
allowing these powerful techniques to help with their health mainte-
nance and their ability to cope with chronic conditions. Remind them
to be patient, steadfast, and to practice without fail. Always empha-
size that they need to make autogenic training a part of their daily ac-
tivities. As time goes on, they will need mere minutes to reap the
benefits of their hard work. In time, they will sleep more restfully and
will wake up more refreshed. Ultimately, they will enjoy life more
fully despite their chronic conditions.
CASE EXAMPLE
SC was a forty-two-year-old female who came to see me for pain

management. At the age of thirty-five she was diagnosed with rheu-
matoid arthritis and later with fibromyalgia pain syndrome. Up to the
time of her first visit with me, SC’s treatment had primarily been
based on the trial of different medications, some of which had effec-
tively arrested the progression of her arthritis. She was, however, in
some pain and discomfort on a regular basis and did not want to try
stronger medications because of a fear of becoming dependent on
narcotics. She had also suffered from bouts of depression secondary
to her pain as a consequence of feeling helpless about the prognosis
of her condition. In addition, she developed some difficulties with her
sleep cycles, especially in terms of sleep-onset latency (it took her

several hours to fall asleep) and sleep maintenance (she experienced
sudden awakenings from deep sleep at least four times a night).
After the initial interview, SC related to me that she was highly
motivated to try the autogenic techniques. She spoke with several pa-
tients who were doing well with autogenic training, and I was most
impressed with her resolve and determination. She recorded detailed
data during her home practice with the standard exercises, which sub-
stantially helped with her progress. After completing training in the
six exercises, I saw her every four to six weeks and was very pleased
with the improvements in her overall functioning. In addition to fol-
lowing a good diet and regular exercise, SC had made autogenic
training an important part of her daily activities. Her rheumatologist
began reducing the dosage of the arthritis medication, especially as
her Sed rate (a general indicator of inflammation) reached the normal
range. When I discharged her from my care, SC was, in her own
words, “a new person.”
Two years after her last session with me, I received a disturbing
phone call from SC. She related to me that she had fallen down the
stairs while she was washing the windows and was experiencing a
significant setback in her condition. Her physicians were closely
monitoring her condition and had put her on stronger medication for
pain control. Most unsettling to SC was her inability to achieve a
deep state of relaxation with the use of the autogenic exercises. After
two sessions of reviewing the basic exercises, I decided to take her
through the meditative exercises. In approximately six weeks, SC was
effectively using the second meditative exercise on a daily basis.
Soon she was able to enter a much deeper state of relaxation with
greater rapidity. In time, SC was able to enter the autogenic state by
simply thinking about “her color” (light blue) for two to three min-
utes. She is now proficient in all the meditative exercises and from
time to time sends me a postcard updating her progress.
Chapter 15
Autogenic Training and Biofeedback
Long before the term “biofeedback” was coined, the pioneers of

autogenic training made use of physiological measures as a way
of substantiating the effects and the effectiveness of their technique.
However, the information was seldom directly disclosed to the trainee.
It was not until the late 1960s that Elmer and Alyce Green successfully
combined autogenic formulas with temperature biofeedback to treat a
variety of stress-related conditions such as essential hypertension and
migraine headaches (Green and Green, 1977). Later on, the first study
conducted to treat migraine headaches with the use of autogenic bio-
feedback was published by Sargent, Green, and Walters (1972).
The combination of autogenic training and biofeedback provides a
potent methodology for treating a wide range of medical and psycho-
logical complications. For example, as the patient repeats the various
autogenic formulas, he or she is provided with verbal (usually early in
the treatment) and later with electronic biofeedback about his or her
physiological functions (most often peripheral temperature and mus-
cular activity). This strategy can significantly improve the patient’s
confidence in that the mere repetition and visualization of the formulas
can bring about instantaneous physical changes, even if they are not
readily perceived. This realization is especially important for patients
with chronic conditions who often tend to feel helpless and powerless
with little or no control over their symptoms. With the appropriate use of
autogenic biofeedback, patients will quickly observe how much con-
trol they can actually exert over their unconscious physiological func-
tions. This newly acknowledged sense of self-efficacy is perhaps the
most important reason why psychophysiological modalities have been
so effective in the treatment of a variety of disorders.
165
WHAT IS BIOFEEDBACK?
The term biofeedback literally means to provide individuals with

information about their vital or biological processes. An oral ther-
mometer, a stethoscope, and a blood pressure unit are instruments
used to provide information about biological processes. However, in
the actual biofeedback training patients are provided with continuous
feedback or information. Depending on the biofeedback modality
that is being used, patients may be able to monitor a biological func-
tion for a few seconds to a few minutes. Immediate feedback can give
patients greater control over the realization of specific functions (e.g.,
blood flow in the hands) through regular practice and by paying at-
tention to the information that is made available through the instru-
mentation. Fuller (1977) defined biofeedback as “the use of instrumen-
tation to mirror psychophysiological (mind-body) processes of which
the individual is not normally aware and which may be brought under
voluntary control. This means giving a person immediate informa-
tion about his or her own biological conditions such as: muscle ten-
sion, skin surface temperatures . . . This feedback enables the
individual to become an active participant in the process of health
maintenance” (p. 3).
To many patients, the term “biofeedback” may conjure up images
of mind control and electrodes attached to their head and connected
to arcane machines. To help patients better understand and further ex-
plore the concept of biofeedback, I often use the following example:
Imagine that you are driving a car and you are instructed to
maintain a speed of 65 miles per hour. You simply comply by
first looking at your speedometer (which gives you information
or feedback about your speed) and then by working the gas
pedal or the brakes to easily adjust your speed so that you are
driving at exactly 65 MPH. The speedometer is clearly the key
that allows you to gain an accurate sense of your speed. In com-
bination with your knowledge of the accelerating or decelerat-
ing you can have full control over your speed. Now as you are
listening to me, if I ask you to raise the temperature of your right
hand, would you be able to comply? Unless you have had some
experience with psychophysiological techniques, it is unlikely
Autogenic Training and Biofeedback 167
that you will be able to accomplish such a task because there is

no way for you to know whether you are actually raising or de-
creasing your temperature. If I attach a small digital thermome-
ter to one of your fingers and provide you with instantaneous
information about your hand temperature, it will be only a mat-
ter of time before you can learn methods of changing the blood
flow in your hand. You may spend a few minutes and imagine
that you are lying on warm sand at the beach or sitting in a hot
tub and enjoying the warmth that relaxes your tired muscles.
With the use of a biofeedback thermometer and by focusing on
such images you can quickly discover whether these images ac-
complish your desired outcome.
Biofeedback instruments can provide patients information through

a variety of sensory modalities. For example, a meter or a graph can
immediately show changes in hand temperature. Instead of seeing
these changes, a biofeedback unit can be set or programmed to pro-
vide information via a descending or an ascending tone. Based on
the patient’s preference, one can adjust the unit so that it produces a
tone that gets louder (ascending) as the hand temperature goes up or
have it do the opposite (the tone gets softer as the temperature rises).
Some biofeedback machines can also provide tactile feedback which
gives the patient a mild vibration as he or she brings about the desired
changes.
WHAT IS AUTOGENIC BIOFEEDBACK?
With the use of biofeedback instruments, patients will learn which

images are helpful in changing their hand temperature or muscle ten-
sion. For some people, the mere image of being at the beach may be
sufficient to do this. However, others may actually notice a decrease
in their temperature because of such images. Hence, educational and
the subsequent therapeutic implications of a simple biofeedback pro-
cess can be immensely rewarding.
What if we combine the well-established autogenic formulas with
various forms of biofeedback? For example, while practicing the first
standard autogenic exercise, heaviness, we provide the patient with
information about his or her muscular activity of the right arm. In a

short while, the patient can see or hear that the repetition of such for-
mulas can result in a change in the tension levels in specific muscles.
The combination of autogenic training and biofeedback can be highly
helpful in retraining certain aspects of the nervous system that may be
overfunctioning due to the prolonged experience of pain and stress.
In 1966, Alyce Green developed the following “classic” phrases for
autogenic biofeedback. While these phrases have certain components
of the standard autogenic exercises, they are also unique and encom-
pass other sensations and experiences. For example, they address quiet
thoughts and an inward state of peace and stillness. In my opinion,
these should be used only after training in the standard exercises:
• I feel quite quiet.

• I am beginning to feel quite relaxed.
• My feet feel heavy and relaxed.
• My ankles, my knees, and my hips feel heavy, relaxed, and
comfortable.
• My solar plexus and the whole central portion of my body feels
relaxed and quiet.
• My hands, arms, and my shoulders feel heavy, relaxed, and
comfortable.
• My neck, my jaws, and my forehead feel relaxed. They feel
comfortable and smooth.
• My whole body feels quite heavy, comfortable, and relaxed.
• I am quite relaxed.
• My arms and hands are heavy and warm.
• I feel quite quiet.
• My whole body is relaxed, and my hands are warm, relaxed and
warm.
• My hands are warm.
• Warmth is flowing into my hands. They are warm, warm.
• I can feel the warmth flowing down my arms into my hands.
• My hands are warm, relaxed and warm.
• My whole body feels quiet, comfortable, and relaxed.
• I withdraw my thoughts from the surroundings and I feel serene
and still.
Autogenic Training and Biofeedback 169
• My thoughts are turned inward and I am at ease.

• Deep within my mind, I can visualize and experience myself as
relaxed, comfortable, and still.
• I am alert, but in an easy, quiet, inward-turned way.
• My mind is calm and quiet.
• I feel an inward quietness. (in Green and Green, 1977, pp. 337-
338)
With the use of the biofeedback instruments, the patient no longer

needs to believe that the formulas work; he or she can see a record of
progress from moment to moment, and from session to session. After
a while, the patient no longer needs the machinery to know whether
the desired changes are taking place.
The most common biofeedback units are:
1. Peripheral Temperature Biofeedback: A small sensor is at-

tached to a finger to gain information about the blood flow in the
hands (or the feet), and to learn to increase blood flow to en-
hance relaxation and pain control.
2. Surface Electromyographic Biofeedback: Small sensors are at-
tached to the surface of a muscle in order to observe the activity
of the muscle and to learn to reduce tension in that muscle.
3. Electrodermal Response Biofeedback: Small probes are at-
tached to a hand that allows the monitoring of the activity of the
sympathetic nervous system which is involved in the stress re-
sponse. By reducing this activity, one can significantly enhance
the ability to relax.
ARE BIOFEEDBACK INSTRUMENTS NECESSARY

FOR AUTOGENIC TRAINING?
The answer to this question is no. Biofeedback can help patients

gain greater knowledge about the functioning of certain aspects of
their nervous system but this knowledge can also be achieved through
the regular practice of autogenic exercises. I have found autogenic
biofeedback to be of special value to those patients who have con-
vinced themselves that nothing they can do will change their pain,
their cold hands and feet, etc. In this sense, autogenic biofeedback
can initially be used as a way of empowering patients and showing
them that they do indeed have some control over their body. This pro-
cess by itself is highly therapeutic and can significantly diminish the
feeling of helplessness that is often experienced when one grapples
with chronic conditions. As a rule, I do not immediately introduce
biofeedback into my sessions because I do not want patients to expe-
rience “performance anxiety.” That is to say, I want patients to focus
on learning new and more effective responses, instead of merely fo-
cusing on changing a certain physiological parameter. A good ses-
sion is more than just changing the dials or the numbers; it is about
becoming aware of the process involved in such changes. In other
words, learning is just as important as performance. Initially, I pro-
vide patients with some general information about their peripheral
temperature or changes in muscle tension and eventually give them
more continuous feedback. Some patients are also provided with a
small portable biofeedback unit for home practice (especially for the
treatment of migraine headaches in which the use of portable temper-
ature units can be extremely helpful).
Chapter 16
Sleep, Insomnia, and Pain
Oh sleep! it is a gentle thing,

Beloved from pole to pole!
To Mary Queen the praise be given!
She sent the gentle sleep from Heaven,
That slides into my soul.
Coleridge
Sleep is that aspect of our existence that we tend to take for

granted. Yet more and more scientific studies suggest that sleep plays
a significant role in our physical and mental health. After a long and
busy day, people tend to go to bed and expect to close their eyes and
enter the realm of forgetfulness and rest. When it does not happen,
they hope to find the remedy in a bottle of pills.
Since the dawn of human civilization, in every known culture,
speculation has surfaced about the nature of nightly slumber. To
some it was quite clear that the renewal of the human spirit relied so
heavily on the night journey that without it, sickness and disease were
bound to happen. Great poets such as Shakespeare referred to sleep as
nature’s nurse whose absence signaled the coming of mental anguish
and turmoil. To make sure that sleep was not compromised or inad-
vertently interfered with, different cultures devised certain rituals
that were closely observed every night. Perhaps the most common
component of such rituals shared cross-culturally was reciting spe-
cial bedtime prayers (see Foulks, 1992). Researchers are just begin-
ning to appreciate the role of these types of prayers in promoting
better sleep. How? It has become quite clear in recent years that one
of the worst enemies of sleep is an overactive mind, or, as it was dis-
171
cussed earlier, a mind suffering from cognitive anxiety. Prayer, espe-

cially repetitive prayer, tends to quiet the busy mind and bring some
semblance of peace.
Since the invention of the electroencephalogram (EEG) by Hans
Burger in 1929, investigators have learned a great deal about the com-
plexities and intricacies of sleep. It is now well established that sleep
is comprised of a number of overlapping stages that tend to be re-
sponsible for a variety of physical and mental changes. In addition,
recent studies suggest that during sleep a variety of biochemical and
physiological changes occur that play an important role in health
maintenance (Vgontzas et al., 1999). Significant findings suggest
that important changes in immune system activity occur during the
nightly slumber. Both human and animal studies suggest that even
partial awakening can affect the responsiveness of the immune sys-
tem and interfere with its effective vigilance (Irwin, Smith, and
Gillin, 1992).
These and other findings should convince one to pay greater atten-
tion to his or her sleep hygiene and do whatever it takes to enhance its
recuperative and restorative functions. To achieve this task, a brief re-
view of the different stages of sleep and its neurophysiology is in order.
THE STAGES OF SLEEP
First, let us briefly discuss the various stages of sleep. Generally

speaking, sleep is comprised of two distinct stages: non-rapid eye
movement (NREM) sleep and REM sleep (or the rapid eye move-
ment sleep, which is often associated with dreaming). The NREM
sleep is divided into four overlapping stages.
1. Stage 1 sleep is considered the lightest stage of sleep and can

easily be interrupted. During this stage, people may be aware of
some events in their immediate environment, such as noise,
light, etc. EEG recordings during Stage 1 suggest a gradual
slowing of the brain wave activity.
2. Stage 2 sleep is characterized by a further slowing down of the
electrical activity of the brain and the presence of special wave
forms known as the sleep spindle. During this stage awareness
Sleep, Insomnia, and Pain 173
of environmental stimuli is significantly lessened, although it is

still possible to wake a person with little difficulty.
3. Stage 3 sleep is notable for a significant reduction in the overall
metabolic activity. During this stage it is much more difficult to
wake a person. The body’s core temperature begins to fall grad-
ually. Pulse and breathing rates tend to drop. If awakened, an in-
dividual may appear somewhat disoriented and unable to recall
thoughts or dreamlike images.
4. Stage 4 sleep is the deepest stage of rest, both physiologically
and mentally. Large delta waves dominate the EEG activity.
Several studies have documented an increase in the production
of the somatotropin, the growth hormone, during this stage of
sleep (Luce, 1970; Vgontzas et al., 1999). Many researchers
have referred to this stage as restorative sleep, since many repair
processes take place at this stage (Dement, 1999). If awakened
during this stage, an individual may be quite disoriented and
momentarily unable to recall even simple information. Stage 4,
or delta sleep has been of significant interest to scientists study-
ing chronic pain and fibromyalgia. An inexplicable phenome-
non of Stage 4 interruption, known as alpha intrusion has been
documented in most fibromyalgia and many chronic pain pa-
tients (see Moldofsky et al., 1975). We shall discuss some of the
scientific studies that have explored this later in the chapter.
Rapid eye movement (REM) sleep takes place at the conclusion of

Stage 4. Here we see a significant increase in brain wave activity as if
the brain is entering a hyperaroused state. During this stage dreaming
takes place, and there is an increase in heart rate, blood pressure, re-
spiratory rate, and overall metabolic functioning. Normally, people
tend to enter REM sleep when they approach the early hours of the
morning.
Now that we have some understanding of the different stages of
sleep, let us now consider some of the other aspects of this complex
and vital process. Sleep onset latency refers to the length of time that
is required before entering Stage 1 sleep. Normally, it takes some-
where between ten and twenty minutes to fall asleep. If it takes longer
than that, this may suggest that the person is suffering from sleep-on-
set insomnia. I have worked with many chronic pain and fibro-
myalgia patients who required somewhere between three to five

hours to initiate sleep.
An entire sleep cycle, starting with Stage 1 and ending with REM
sleep tends to occur within a 90- to 110-minute period. When too
much mental activity or physical discomfort occurs, people are likely
to spend more time in the earlier stages of sleep. As a rule, children
tend to spend more time in the deeper stages of sleep, possibly be-
cause of the need for replenishing the biochemicals necessary for
growth and repair.
Some of the most recent studies suggest that most people require at
least eight hours of sleep (see Dement, 1999). Based on these same
studies, it is safe to say that the United States is a nation of insomni-
acs. Most of us tend to get less than eight hours of sleep, and the prob-
lem is not going away. At the same time it is important to note that
spending too much time in bed can also be problematic. Due to a re-
duction in respiration rate and metabolic function, those who sleep
for more than ten hours tend to wake up tired, disoriented, and may
actually suffer from headaches.
Stage 4 Sleep and Fibromyalgia: Is There a Connection?
Almost every publication on fibromyalgia points out that alter-

ations in Stage 4 activity occur in patients suffering from this condi-
tion.
In 1975, Moldofsky and colleagues published a paper titled, “Muscu-
loskeletal Symptoms and Non-REM Sleep Disturbance in Patients
with Fibrositis Syndrome and Healthy Subjects” (Moldofsky et al.,
1975). The study’s conclusions were twofold. First, it was clearly dem-
onstrated that “fibrositis” (fibromyalgia) patients showed a disruption
in the Stage 4 sleep as indicated by an intrusion of Alpha waves. Sec-
ond, healthy subjects who were deprived of Stage 4 sleep (via a loud
sound) began experiencing muscle pains and changes in their moods
consistent with those observed in fibrositis patients. The study also
suggested that since key brain chemicals are produced, metabolized,
and synthesized in this stage of sleep, a chronic disruption in deep
sleep may be one of the contributing factors to the appearance of symp-
toms in the fibrositis patients.
Twenty-five years have elapsed since the publication of this ground-

breaking study. The study itself has been replicated several times
with almost identical results. I have looked at hundreds of sleep stud-
ies of fibromyalgia patients which supported the findings of the
Moldofsky study. But sleep disturbance alone does not seem to be
the cause of fibromyalgia (fibrositis) syndrome. The alpha intrusion
phenomenon has been seen also in chronic pain patients who do not
suffer from fibromyalgia. A study by Leventhal and colleagues (1995)
suggested that the disruption of Stage 4 sleep may be more of a “gen-
eralized marker for chronic pain rather than a specific anomaly in pa-
tients with FM” (p. 110).
From these studies we can conclude that Stage 4 sleep plays a key
role in fibromyalgia and chronic pain even though it may not be the
primary cause. Therefore, it behooves us to do whatever necessary to
enhance the sleep process and the quality of Stage 4 sleep. In my ex-
perience, by following certain scientifically supported protocols in
conjunction with autogenic training, it is possible to bring about a
significant change not only in the overall quality of sleep but also
changes in physical and cognitive symptoms.
REDUCING COGNITIVE ANXIETY
I have survived more catastrophes than one can possibly imag-

ine . . . only because many of them never came true.
Mark Twain
In my clinical experience with the treatment of sleep disorders, I

have come to conclude that almost all fibromyalgia patients, and the
majority of chronic pain patients, tend to suffer from “too much
thinking and worrying” especially when the time comes for sleep. As
it was pointed out in Chapter 3, this phenomenon is often referred to
as “cognitive anxiety” and it was illustrated how certain relaxation
exercises could potentially reduce the activities of an overactive
mind. Some strategies for reducing cognitive anxiety will be dis-
cussed later in this chapter. Patients should follow the instructions
presented and incorporate them into their presleep activities every

night until these instructions become a natural routine.
No Problem-Solving in Bed
Easier said than done! But this is a key reason that many do not get
the quality rest that they need. Sleep is a time for replenishment and
people should be encouraged not to cheat themselves of this valuable
time by trying to solve problems or address their concerns. They can
accomplish these tasks, if they wish, as soon as they get up in the
morning. I cannot possibly count the number of my patients and stu-
dents who reported an improvement in their sleep by merely follow-
ing this simple rule. I have asked my patients to say the following
affirmation to themselves before falling asleep. “I need my sleep to
heal. Therefore, I will put aside my worries and concerns and allow
myself to rest, refuel, and replenish until morning.”
Talk It Out or Write It Down
Now let us consider a patient who goes to sleep with all the right
attitudes and preparations but cannot fall asleep because of a certain
bothersome topic. In such a case, I suggest that the patient tries to
“talk it out.” Talking to someone who can listen without offering a
thousand suggestions is, in my view, an excellent way of quieting a
busy mind. But if a “listening ear” is not available, the next best thing
is to write down whatever is interfering with falling asleep. Either ap-
proach seems to make an important difference between spending
one’s sleep time thinking about things that cannot be changed and
getting the kind of quality sleep that one deserves.
Relaxing Some of the Expectations About Sleep
After years of developing some bad sleep habits, patients cannot

expect to replace them with new habits overnight. All good things
happen slowly, so patients need to remain steadfast in their new learn-
ing. They also need to let go of certain expectations that may sound
very scientific, but have nothing to do with getting good sleep. The
best way to illustrate this point is to reflect on a discovery by one of
America’s most beloved writers, Mark Twain. The following account

explains how he discovered some of his irrational beliefs concerning
sleep:
Mark Twain was a cantankerous insomniac. Once the author

found himself at a friend’s home, unable to sleep. The problem
was not a new one to Twain, yet he convinced himself that the
reason for his failure to sleep was the poor ventilation in the un-
familiar room. He tossed and turned for some time, cursing the
stuffy atmosphere. Finally, in a fit of anger, he picked up his
shoe and hurled it through the darkness at the window, which he
had been unable to open in the conventional way. He heard the
sound of shattering glass, inhaled deeply and thankfully, and
fell fast asleep. In the morning the well-rested humorist noticed
that the glass-enclosed bookcase had been smashed. The win-
dow was still locked and intact. (Goldberg and Kaufman, 1978,
pp. 38-39)
This story contains a special wisdom which is pertinent to all of us:

at times our suffering is largely of our own creation—namely, our ex-
pectations. As I have pointed out throughout the book, the prolonged
experience of helplessness is perhaps the worst possible source of
damage and destruction to one’s psyche and soul. Certain things in
patients’ lives cannot be controlled nor can they be changed. But pa-
tients can learn to cope. The first step is to teach them how to let go of
self-defeating thoughts and expectations. For example, most chronic
pain patients, in my experience, seem to have given up on getting a
good night’s rest. I often hear them say, “What is the use? I just can’t
sleep anymore.” Obviously after years of disrupted or incomplete sleep,
many conclude that they have lost the ability to sleep. This is an irra-
tional conclusion with devastating ramifications. If patients want to
gain greater control over their pain and physical symptoms, they need
to “relearn” how to sleep. This relearning process requires commit-
ment and steadfastness. In the past, I have worked with patients who
used to sleep for a maximum of two to three hours. After weeks of
following specific instructions, they were able to sleep, with little in-
terruption, for six to eight hours and began noticing improvements in
their pain and overall health.
I am not going to suggest a special pill that will help chronic pain
patients recover from insomnia. Sleeping pills often impair certain
stages of sleep. Although antidepressants tend to help with achieving
deeper sleep, patients can enhance their natural rest and slumber by
other means.
Patients need to be encouraged to adhere without fail to the in-
structions that are stated in pages to come. These instructions are
based on some of the most recent scientific studies on insomnia. The
only way these instructions can be of help is if they are followed with
total determination. There are three points that I often emphasize to
fibromyalgia and chronic pain patients.
1. Taking care of one’s sleep is a critical step in enhancing pain

management.
2. One can do much to improve one’s overall health by getting
more quality sleep.
3. One must adhere to certain scientific findings and principles
that have been shown to improve sleep.
IMPROVING SLEEP
Current scientific studies suggest that two of the most helpful meth-
ods of improving sleep are stimulus control and sleep restriction.
Stimulus Control
The stimulus control approach to improving sleep was first devel-

oped by Richard Bootzin (1972). The main rationale behind this ap-
proach suggests that insomnia can be a conditioned response caused
by associating (or pairing) the bedroom with certain behaviors that
promote arousal instead of sleep. For example, many people do their
problem solving or next-day planning while in bed. Such activities
promote a state of alertness that can significantly interfere with the
ability to fall asleep. Also, many people remain wide awake while ly-
ing in their bed waiting for sleep to arrive. Gradually, the unconscious
association is made that the bed is a place for alertness and not sleep.
This association is why some people tend to fall asleep much more
quickly on the couch in the living room than on the comfortable bed
in the bedroom.
By following certain specific instructions, individuals can gradu-
ally remove or neutralize those associations that tend to keep them
alert and awake while in bed. Following is a list of conditions that
need to be observed to reestablish healthy sleep patterns.
Make the Bedroom a Place for Sleep

The bedroom should not be used for any other activity (with the
exception of intimacy) that will keep one alert. If one tends to do
computer work or write letters or balance the checkbook in the bed-
room, it is time to find a new spot for such activities. Unfortunately,
the television set must go, too.
Do Not Stay in Bed to Force Falling Asleep

If one cannot fall asleep after ten to fifteen minutes of lying in bed,
it is time to leave the bedroom and do something else until sleepy.
People should be encouraged to read a book or watch a TV show in
another room, but return to bed when they become sleepy.
Keep the Bedroom Dark, Quiet, and Cool

Although the stimulus control theory does not emphasize any par-
ticularities about the ambiance of the bedroom, it is important to note
that certain environmental conditions can also keep people more
alert. Reducing environmental stimulation can by itself promote a
state of relaxation, which may serve as a prelude to sleep. Adjust-
ments need to be made to keep the bedroom quiet, dark, and pleas-
antly cool. Blankets and comforters should be used to keep the body
warm, but the room should be kept cool (approximately 68° to 70° F).
Sleep Restriction
This approach is based on the total time that is spent in bed. If peo-
ple are restricted to only a certain number of hours while in bed, they
may find themselves trying to get the most out of those hours in terms
of sleep. For example, if a person is currently sleeping only six hours,
his or her task is to limit the time spent in bed to those six hours. This
person should be encouraged not to stay in bed any longer than six
hours while trying to get some partial sleep. Gradually, the individual
may discover that he or she tends to get a bit more sleep, night after
night. Once the person approaches eight to eight-and-one-half hours
of sleep, he or she has made the necessary adjustments.
Also, it is imperative that one does not take naps during the day. It
is best to restrict one’s sleep time to the time spent in bed at night. Al-
though this may be a challenge in the beginning, most people will
soon discover an improvement in the quality of their nocturnal sleep.
Receiving quality sleep at night, not during the day, is the key to en-
hancing health, improving coping, and refueling the body for the
daily tasks.
Here are some additional suggestions that patients may find very
helpful.
1. Hide the clock. Looking at the clock throughout the night may
actually cause people to become more aroused, which means
that they will need more time to unwind before falling asleep.
2. Take a hot shower before going to bed. Many chronic pain pa-
tients find a hot shower before bedtime is very relaxing and
soothing to their tired muscles. However, they should make sure
that they do not wash their hair since it takes a while for the hair
to dry, and the heat loss may be counterproductive.
3. Take pain medications before going to bed. Patients should ask
their physicians if they can take their analgesics shortly before
bedtime. In order to reduce the sleep-onset latency, it is best to
use certain pain medication ten to twenty minutes before bed-
time so that one is more pain free while trying to sleep.
4. As diurnal creatures, we need to be asleep during the night and
not during the day. Many biochemical corrections that are sig-
nificant for the purpose of pain management are produced at
night. For this reason alone, chronic pain patients, particularly,
must make sure that they are in bed before midnight. It has been
documented that the growth hormone (also know as somatotro-
pin) peaks its production between the hours of 12 a.m. and
4 a.m. (Coleman, 1986). Other studies have suggested that a sig-
nificant reduction occurs in the growth hormone levels in fibro-
myalgia and chronic pain patients. Therefore, it is imperative to
make every attempt to make sure that patients are doing what is
needed to enhance the quality of their sleep at night.
AUTOGENIC TRAINING AND SLEEP
In addition to some of the sleep enhancement techniques that were

discussed earlier in the chapter, relaxation techniques have been used
quite extensively to treat sleep disorders and insomnia. In fact, one of
the popular and widely used relaxation techniques, progressive mus-
cle relaxation, was originally developed by Dr. Edmund Jacobson to
treat insomnia. Transcendental meditation (TM) is another approach
to sleep restoration and has been used extensively in clinical studies
throughout the world. A study by Miskiman (1977) showed that in-
somniacs who typically spent over seventy minutes falling asleep re-
duced this time to approximately fifteen minutes after several months
of practice with TM.
Nicassio and Bootzin (1974) compared the efficacy of autogenic
training, progressive relaxation, a no-treatment control group, and a
self-relaxation control group as treatments for chronic insomnia.
Both autogenic training and progressive relaxation were equally ef-
fective and superior to the control groups in reducing insomnia. At a
six-month follow-up, treatment gains had been maintained over time
for falling asleep but not in self-reported, global improvements. The
subjects in the control groups, however, showed no spontaneous im-
provements on either of the two measures.
As previously discussed, autogenic training evolved from studies
that explored the nature of sleep and its recuperative properties. For
this reason alone, the expansive literature on this technique elucidates
the causes and the treatments of persistent disorders of sleep (Luthe
and Schultz, 1969b; Sadigh and Mierzwa, 1995; Sadigh, 1999). I
have found autogenic training a tremendous help to those who suffer
from chronic pain, and as a result, tend to suffer from insomnia. Often
those who have difficulty with sleep onset latency almost immedi-
ately notice an improvement after practicing the techniques for several
weeks. With some additional instructions, those with difficulty main-
taining their sleep due to frequent waking tend to see improvements
by the time they learn the fourth standard exercise.
As patients progress in their daily practice of the autogenic exer-

cises and they proceed to the third and fourth standard exercises, they
will be able to tackle some of the most difficult cases of insomnia.
Once again it must be emphasized that patients need to follow the in-
structions on stimulus control and sleep restrictions that were dis-
cussed earlier in this chapter to improve their results.
Although patients can use the standard exercises when they go to
bed, I recommend an abbreviated version of these exercises for sleep
enhancement. There are also several specific formulas that can be
used at night as a way of reducing asleep latency and improving sleep
maintenance. Patients need to memorize these formulas and use them
especially if they wake up in the middle of the night and find it diffi-
cult to fall back to sleep.
I recommend a total of three sleep exercises which are based on the
standard and organ-specific formulas. Patients may use the first sleep
exercise as they are mastering the heaviness exercise and the second
sleep exercise as they begin working on the warmth exercise. They
should not proceed to the third sleep exercise until they have started
using the fifth standard exercise (abdominal warmth) during their
daily practice. It is imperative that patients use these exercises every
night, regardless of how tired or sleepy they might feel. These exer-
cises should become a part of their sleep ritual.
Patients may be instructed to use the following exercises while in
bed and as they are about to fall asleep. Each formula is to be repeated
approximately ten times.
Sleep Exercise 1

• I am at peace.
• My right arm is heavy.
• My left arm is heavy.
• I am at peace.
• My shoulders are heavy.
• I am at peace.
• My right leg is heavy.
• My left leg is heavy.
• I am at peace.
• It sleeps me.
Sleep Exercise 2

• I am at peace.
• I am at peace.
• I am at peace.
• I am sleepy and relaxed.
• It sleeps me.
Sleep Exercise 3
Patients should begin this exercise only after they have begun us-
ing the fifth standard exercise.
• I am sleepy and relaxed.

• My legs are heavy and warm
• It breathes me.
• My abdomen is pleasantly warm.*
• Warmth makes me sleepy.
• It sleeps me.
For some patients, it is safe to assume that initially they may have
difficulty staying asleep even though they fall asleep more quickly
*See Chapter 13 for precautions before using this formula.

with the help of autogenic formulas. My recommendation is that as

soon as patients find themselves wide awake in the middle of the
night, they should immediately begin repeating several formulas to
themselves, especially those that focus on sensations of heaviness
and warmth. The key is to repeat these formulas as soon as one is
awakened due to pain or other reasons.
In my experience, the majority of people quickly learn to use the
formulas to fall back to sleep. The key is to persevere. Many patients
report that by repeating one or two formulas they can fall asleep al-
most effortlessly. Some, including myself, find “warmth makes me
sleepy” to be a very helpful “sleep trigger.”
Chapter 17
Questions and Answers
In this section, some of the most commonly asked questions and

answers about autogenic training (and relaxation training in general)
will be presented. Clinicians are likely to encounter similar questions
while treating patients with autogenic exercises. Hence, a review of
the questions and their answers may prove to be of value, especially
in a clinical setting. Readers are also encouraged to consult various
books and papers that have been written about autogenic techniques
that appear in the reference section of this book.
Q: Everybody tells me that I should learn to relax. I have

bought several books on relaxation techniques but I don’t seem
to be able to unwind. Is there something wrong with me?
A: First, many people find it difficult to relax and unwind. That is
why tranquilizers are so commonly used to promote a relaxed state.
Although they give you quick results, unfortunately, tranquilizers
are not without side effects, addiction being the most serious one.
Some people feel that relaxation is a waste of time and that they have
more important things to do. So instead of thinking about relaxation
you should think about replenishing or refueling yourself. Refueling,
which is actually the scientifically accurate term for relaxation,
should help you with the needed motivation to find the right tech-
nique and stay with it.
From this question, I can surmise that you have difficulty quieting
your mind and that your inability to relax may not necessarily be a
physical problem. Many relaxation techniques focus on relaxing the
body, and if you have been trying these techniques you probably have
discovered that they do not particularly help your racing mind. You
185
need to find a technique that preferably quiets both your mind and re-
laxes your body. Autogenic training may be of great help to you.
However, please remember that you should not expect overnight re-
sults. If you adhere to the instructions that are provided in this book, it
is quite possible that within the first two weeks you should begin no-
ticing some replenishing, rejuvenating results. Keep practicing and
you should see results.
Q: Is autogenic training a form of hypnosis?

A: I am often asked this question during the first training session
because of the focus on heaviness. The origin of autogenic training
was based on certain scientific observations and discoveries from the
field of medical hypnosis. However, the field of autogenic training
has gone far beyond autosuggestions. Many of the processes that are
promoted during autogenic training are based on physiological ob-
servations during sleep and when the body enters a repair process
similar to what happens in a pre-sleep state. From EEG studies of the
hypnotic state we know that hypnosis tends to occur more in an alert
state. In addition, the autogenic formulas are physiologically based.
That is, they are not just based on some relaxing suggestions. As the
nervous system enters a state of repair and recuperation from stress,
the muscles do become more relaxed, the peripheral temperature
rises, the heartbeat becomes more steady, etc. The autogenic formu-
las simply support and enhance the same process. That is why it is
called autogenic: it is brain directed or self-generated. With autogenic
training there are no posthypnotic suggestions. The formulas are
physiologically based and are not based on suggestions about merely
inducing a state of relaxation.
Q: I am quite overweight and just the thought of repeating to

myself that my arms and legs are heavy is very unsettling. What
should I do?
A: The heaviness formulas focus on the sensation of heaviness, a
tranquil and soothing sensation that we often experience before fall-
ing asleep. Keep your focus on that sensation and not on the muscle
mass. As you repeat the formula, imagine that your muscles are be-
coming relaxed and totally free of any tension.
Questions and Answers 187
Q: I have been practicing Yoga (Hatha Yoga) for some time but
I seem to have stopped benefiting from it. Can I combine Yoga
with this (autogenic) technique?
A: Hatha Yoga is a wonderful technique for stress management,
pain management, and overall health enhancement. However, it has
been recommended that you do not combine any other techniques, no
matter how therapeutically helpful, with autogenic training. The se-
quence of autogenic formulas has been developed based on decades of
intensive research into the dynamics of self-regeneration and a brain-
generated process of reestablishing homeostasis (state of balance). It is
quite possible that by introducing additional activities into the se-
quence of formulas, you may inadvertently interfere with the actual
autogenic process, and may possibly bring on some paradoxical ef-
fects. My recommendation is that you practice the two techniques at
different times during the day and refrain from combining them.
Q: I feel that if I say, “my arms and shoulders are light,” in-
stead of heavy, I may enter a deeper state of relaxation. Is there
any harm in doing that?
A: It is imperative that you do not, at any time change or alter the
autogenic formulas. Remember that these formulas are based on
many years of research and they attempt to estimate some of the natu-
ral sensations that we experience shortly before falling asleep. In a
study by Blizard, Cowings, and Miller (1975) it was decided to
change some of the autogenic formulas to see if similar, physiologi-
cally corrective phenomena occurred. For example, the subjects in
the study were asked to repeat formulas that suggested lighter and
cooler extremities. The findings of the study clearly showed that such
formulas actually resulted in an increase in the activity of the sympa-
thetic nervous system which is responsible for the stress response.
For example, an increase occurred in the heart and respiration rates in
those subjects who repeated the light and cool formulas. Meanwhile,
it is possible that while people are repeating the heaviness formulas
they may initially experience a pleasant sensation which is more sim-
ilar to the experience of “lightness” in the extremities. However, you
should not purposely try to induce such a sensation as far the practice
of autogenic exercises is concerned.
Q: I became very excited when I learned that the autogenic

meditative exercises can be used to further add depth to my abil-
ity to relax. There is, however, a big problem for me. I don’t think
I can visualize colors. Even my dreams are in black and white.
Does this mean that I am not a good candidate for the advanced,
meditative exercises?
A: Not at all. I recall that I personally had the same concerns when
I was studying advanced autogenic training. So allow me to share
some of my own experiences with you. First, the color gray has many
shades—a color that is most easily observed shortly after we close
our eyes. Your autogenic color may be a shade of gray that in time,
and with some practice, you will learn to recognize and generate dur-
ing the practice of the autogenic-meditative exercises. I recall that
during the practice of the first meditative exercise, I spontaneously
began to visualize a dark shade of blue and gradually other colors be-
gan to enter my visual field. I also noticed that I gradually began to
dream in color which has persisted to this day. So, my recommenda-
tion is that you focus on different shades of grey and be open to visu-
alizing other colors.
Q: What if a persistent thought keeps showing up during the

practice of the autogenic phrases? What if ignoring the thought
does not seem to do the trick?
A: This is a very common question that requires deeper exploration
as to the cause of such distractions. I can only provide some general
guidelines to remedy the problem. Perhaps the most expedient way of
addressing the problem of distraction is to initially shorten the period
of training, such as starting with only two to three minutes of practice.
Then, as you become more comfortable with letting go of your mental
distractions, you may add a few more minutes to each training (prac-
tice) session. In a clinical setting, patients can effectively overcome
persistent mental distractions by talking about their thoughts, worries,
and concerns. If you don’t have access to your therapist while practic-
ing at home, I recommend writing down your thoughts. This practice
often has a profound effect on reducing mental or cognitive anxiety.
Finally, my patients find the following affirmation very helpful: “I
need to replenish my resources by relaxing my body and mind. I will
Questions and Answers 189
therefore allow myself to put aside my thoughts and worries for the
next ten (fifteen, twenty) minutes and will return to my concerns much
more refreshed at the end of the exercise.” Incidently, many patients re-
port that by the end of the exercise they have no desire to entertain trou-
blesome thoughts and ideas.
Q: I am very interested in this technique and have read much

about it. However, each time I try to practice, I fall asleep. Do you
have a suggestion?
A: You can do several things to reduce the chances of falling
asleep during your training sessions. First, choose a training posture
other than the “Horizontal Posture” (Chapter 6). You may instead
choose the sitting position or the reclined position. Second, you may
want to reconsider the period that you put aside for your practice.
Some people do much better in the early afternoon, while some prefer
the early morning to practice. Finally, there are several formulas that
you may wish to repeat to yourself prior to repeating the standard for-
mulas. These appear in Chapter 12.
Q: How long does it usually take before one begins to see some
results from practicing this technique?
A: This is a difficult question to answer. In my experience, almost
everyone masters the technique at their own pace. Those who have
been in pain or exposed to prolonged stress may need more time to
benefit from the therapeutic effects of this approach. As a general
rule, two to three weeks after practicing the technique, most people
begin to report positive changes in their symptoms. The pioneers of
autogenic training stated that it may take as long as six months before
positive effects are experienced. However, with daily practice, I have
seen steady results in some of the most difficult cases in as early as six
to eight weeks.
Q: How often should I practice and what are the best times for
daily practice?
A: At least initially, you should make sure to practice twice a day
for approximately twenty minutes. The autogenic literature recom-
mends practicing around 12 p.m. or 1 p.m. and also every evening
(about an hour after or before you eat your dinner). You may have to
discover on your own what is the best time for you. In time, you will
be able to enter the autogenic state in minutes, but meanwhile you
should keep practicing until you reach that point.
Q: Many years ago I used autogenic training to control my

headaches and I had very good results. I was recently diagnosed
with FM but I don’t seem to be able to warm up my hands or
calm my breathing the way I used to. What do you think is the
problem?
A: First make sure that you remain under medical supervision
while practicing the autogenic exercises. It is possible that changes in
your health have resulted in overactivation of the stress response—a
condition which is often observed with chronic pain and fibro-
myalgia patients. Next, you may need to begin with the first standard
exercise for a while and then move to the warmth, heart, and breath-
ing exercises. It may take a while before you can warm your hands
but it is worth it. Above all, do not try to force yourself to warm your
hands and/or calm your breathing. Such attempts may result in para-
doxical responses. You may actually feel more anxious while relaxing.
Q: What do you mean by the formula “it breathes me?”

A: What happens to your respiration when you fall asleep? What
happens to your cardiac and digestive activities? Do they cease to
function because you are asleep? One hopes not! Most of the life-sus-
taining functions of the body are not under our conscious control. The
brain contains an elaborate network of self-regulating mechanisms
that constantly monitor and attempt to balance the activities of these
functions. Your respiratory mechanism knows how to breathe effec-
tively without your assistance . . . it knows how to breathe. So the
word “it” refers to unconscious physiological mechanisms that are
constantly working to maintain a state of vitality and balance within
the body.
Appendix A
The Autogenic Pain and Tension

Checklists
(Forms A and B)
These checklists were developed to provide patients with information

about their pain or tension levels before and after each training session.
191
THE AUTOGENIC PAIN CHECKLIST
FORM A
NAME______________ EXERCISE: I II III IV V VI (CIRCLE ONE)
INSTRUCTIONS: Complete this form before your autogenic training ses-

sion. Simply rate your pain levels by circling the number on a scale of 0 to
10. A score of 0 indicates the absence of pain, whereas a score of 10 indi-
cates severe pain in that body part.
NO PAIN SEVERE PAIN
1. My right arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
2. My left arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
3. My shoulders are 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
4. My neck is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
5. My forehead is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
6. My jaw is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
7. My chest is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
8. My abdomen is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
9. My lower back is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
10. My right leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
11. My left leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
12. Overall my body is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
Copyright © 1989 by Micah R. Sadigh, PhD

The Autogenic Pain and Tension Checklists 193
THE AUTOGENIC PAIN CHECKLIST
FORM B
INSTRUCTIONS: Complete this form after your autogenic training ses-

sion. Simply rate your pain levels by circling the number on a scale of 0 to
10. A score of 0 indicates the absence of pain, whereas a score of 10 indi-
cates severe pain in that body part.
NO PAIN SEVERE PAIN
1. My right arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
2. My left arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
3. My shoulders are 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
4. My neck is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
5. My forehead is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
6. My jaw is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
7. My chest is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
8. My abdomen is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
9. My lower back is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
10. My right leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
11. My left leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10

THE AUTOGENIC TENSION CHECKLIST
FORM A
INSTRUCTIONS: Complete this form before your autogenic training ses-

sion. Simply rate your tension levels by circling the number on a scale of 0
to 10. A score of 0 indicates total relaxation, whereas a score of 10 indicates
intense tension in that body part.
RELAXED TENSE
1. My right arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
2. My left arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
3. My shoulders are 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
4. My neck is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
5. My forehead is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
6. My jaw is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
7. My chest is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
8. My abdomen is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
9. My lower back is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
10. My right leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
11. My left leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10

The Autogenic Pain and Tension Checklists 195
THE AUTOGENIC TENSION CHECKLIST
FORM B
INSTRUCTIONS: Complete this form after your autogenic training ses-

sion. Simply rate your tension levels by circling the number on a scale of 0
to 10. A score of 0 indicates total relaxation, whereas a score of 10 indicates
intense tension in that body part.
RELAXED TENSE
1. My right arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
2. My left arm is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
3. My shoulders are 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
4. My neck is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
5. My forehead is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
6. My jaw is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
7. My chest is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
8. My abdomen is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
9. My lower back is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
10. My right leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10
11. My left leg is 0.....1.....2.....3.....4.....5.....6.....7.....8.....9.....10

Appendix B
The Autogenic Training Progress Index
This Index was developed to provide patients with information about

their mastery of the different standard exercises. The Index is completed at
the end of training in each of the standard exercises.
197
THE AUTOGENIC TRAINING PROGRESS INDEX
The First Standard Exercise: Heaviness
Mild sensation of heaviness Profound sensation of heaviness
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
The Second Standard Exercise: Warmth
Mild sensation of warmth Profound sensation of warmth
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
The Third Standard Exercise: Heart
Tense cardiac activity Calm cardiac activity
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
Copyright © 1991 by Micah P. Sadigh, PhD.

The Autogenic Training Progress Index 199
The Fourth Standard Exercise: Respiration
Tense respiration Calm respiration
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
The Fifth Standard Exercise: Abdominal Warmth
Little sensation of warmth Pleasant sensation of warmth
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
The Sixth Standard Exercise: Forehead Cooling
Little cooling sensation Pleasant cooling sensation
|----------| ---------| ---------| ---------| ---------| ---------| ---------| ---------| ----------|
1 2 3 4 5 6 7 8 9 10
Copyright © 1991 by Micah P. Sadigh, PhD.

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Index
Page numbers followed by the letter “f” indicate figures; those followed by the letter
“t” indicate tables.
Abdominal warmth exercise, 127-135 Autogenic process, elements of, 59-61

Achterberg, J., 45 Autogenic state
Adams, N., 13 compared to hypnosis, 59-60, 186
Adrenal insufficiency and muscle compared to sleep state, 60, 76-77,
impairment, 35-36 77f
Affirmations, compared to intentional Autogenic training, 4-6, 44
formulas, 150 areas of use studied, 60
Amitriptyline in treatment of benefits of, 61
fibromyalgia, 19-20 and biofeedback, 167-170
Anderson, C., 37, 39, 42 combining with Yoga, 187
Anisman, H., 26, 27 in Europe and Japan, 61
Antidepressants in treatment of general instructions before starting,
fibromyalgia, 19-20 85-86
Anxiety goal-directed, 77, 80
cognitive and sleep, 175-178 guidelines for, 96t
cognitive versus somatic anxiety, 50 history of, 55-59
in fibromyalgia patients, 14 medical screening for, 63, 64-66
lessening of after heart exercise, 114 medications to be monitored during,
Appropriate mind-set, 97-98 64
Arms pre-exercise checklist, 97t
creating warmth in, 107 preparing for, 85-93
relieving tension in side effects of, 63
when in horizontal position, 74-75
when in reclining position, 71
Arnold, L. M., 20
Arthritis, compared to fibromyalgia, 13, 14 Baker, T. B., 49
Asthma, formulas not be used during Banks, S., 21, 60
attack of, 149 Banner, C. N., 60
Attention and passivity, balancing, 78 Baxter, J. D., 35
Autogenic discharges, 58-59 Beary, J. F., 49
Autogenic meditation. See Meditation, Beck, A. T., 38
autogenic Bennett, R. M., 15, 16
211
Benson, H., 44, 46, 47, 49 Cathey, M. A., 14
Berman, B. M., 4, 37 Centers for Disease Control, 11
Bhagavad Gita, 47 Charlesworth, E. A., 25, 27
Biofeedback, 39-40, 166-167 Chronic pain, and stress, 25
and autogenic training, 165-170 Clauw, D. J., 12, 15
instruments used for, 167, 169, 170 Cognitive anxiety
in treatment of fibromyalgia, 20-22 reducing to improve sleep, 175-178
Biopsychosocial model of medicine, 2-3 versus somatic anxiety, 50
Blacker, H. M., 60 Cognitive relaxation, 49-50
Blanks, S. M., 3 Cognitive restructuring, 38-39
Blizard, D., 187 Cohen, S., 27, 36
Blumberger, S. R., 58 Cold hands and feet, 105
Body, making mental contact with, Coleman, R. M., 180
78-79, 81-82, 90-93 Collecting data about patient’s pain, 93
Boersma, J. W., 35 Colors
Bonica, J., 9 problem in visualizing, 188
Bootzin, R., 178, 181 and relaxation, 162, 163
Borkovec, T. D., 65 visualizing
Breathing, diaphragmatic, 119 spontaneous, 152-153
Breathing exercises suggested, 153-155
autogenic. See Respiration exercise Compound 606, 1
general, 44-45 Concentration, passive, 59, 75-78, 81,
Brodmann, Korbinian, and study of 152
sleep, 56 Concepts, visualization of, 157-158
Bruce, D. F., 19 Cooling and relaxation, 137-139
Budzynski, T. H., 40 Coping skills, in stress inoculation
training, 41
Counting exhalations, 45
Courmel, K., 15
Calabro, J. J., 13 Coursey, R. D., 60
Calves, relieving tension in, 71 Cousins, M. J., 9
Campbell, M. J., 35 Cowings, P., 187
Campbell, S. M., 12-13 Cox, I. M., 35
Cannon, W. B., 33
Cardiovascular training in treatment of
fibromyalgia, 22 Daily practice of autogenic training,
Carette, S., 20 80-81, 82
Carol, M. P., 49 Danish, D., 17, 22
Carrington, P., 47 Data on pain, collecting, 93
Carson, M. A., 43 Davidson, R. J., 45, 49, 50
Case examples de Kloet, E. R., 35
abdominal warmth, 135 Dement, W. C., 173, 174
forehead cooling, 142-143 Dependence on therapist, decreasing,
heart, 117-118 57-58
heaviness, 103-104 Depression in fibromyalgia patients, 14
meditation, autogenic, 162-163 Derogatis, L. R., 21
respiration, 124-125 Diabetes, and abdominal warmth
warmth, 108-109, 110-111 exercise, 127-128
Index 213
Disease(s) Exercise(s) (continued)
to be monitored during autogenic heart (third)
training, 64-65 case example, 117-118
pathogenic origins of, 1 common difficulties with, 116-117
prevention related to relaxation discussed, 113-115
therapy, 43 performing, 115-116
Disregulation model. See heaviness (first)
Psychobiological disregulation case example, 103-104
and fibromyalgia common difficulties with, 102-193
Distractions, mental, 188-189 discussed, 95-99
Doongaji, D. R., 47, 48 and overweight patients, 186
Dowson, D., 35 performing brief, 99-100
Dusek, D. E., 25, 32 performing extended, 100-102
respiration (fourth)
case example, 124-125
Egyptians, ancient, and use of imagery common difficulties with, 123-124
for relaxation, 42 compared with other breathing
Ehrlich, Paul, 1 techniques, 120
Eisdorfer, C., 26 discussed, 119-121
Eisinger, J., 35 performing, 122-123
Electromyographic feedback (EMG), for sleep, 181-184
39-40 time required for, 189-190
Elements of autogenic process, 59-61 warmth (second)
Elliot, G. R., 26 case examples, 108-109, 110-111
EMG (electromyographic feedback), common difficulties with, 109-110
39-40 discussed, 105-107
Ending exercises correctly, 95, 101, performing, 107-109
109, 134, 135 Exhalations, counting, 45
Engel, G. L., 2
English, E. H., 49
Environmental stimulation, reducing, Fahrion, S. L., 97
67-71, 81 Falling asleep during exercises, 189
Everly, G. S., 25, 32 Fatigue in fibromyalgia patients, 13
Exercise(s). See also Formulas Feeling, experiencing a specific state
abbreviated forms of, 145-148 of, 159
abdominal warmth (fifth) Feet and hands, cold, 105
case example, 135 Ferraccioli, G., 20-21
common difficulties with, 134-135 Fibromyalgia
discussed, 127-131 accompanying conditions, 12-13
performing, 132-134 anxiety in patients with, 10-11, 14
checklist before starting, 97t compared to arthritis, 13, 14
ending correctly, 95, 101, 109, 134, 135 compared to myofascial pain
falling asleep during, 189 syndrome, 16-17
forehead cooling (sixth) costs of, 9-10
case example, 142-143 criteria for diagnosis of, 18t
common difficulties with, 141-142 depression in patients with, 10-11, 14
discussed, 137-139 diagnosing, 17-18
performing, 139-141 learned helplessness in, 14
Fibromyalgia (continued) Genest, M., 39
overview of, 9-13 Germ Theory of Louis Pasteur, 1
and psychobiological disregulation, Ghirelli, L., 20-21
23-24 Gillin, J. C., 172
psychological aspects of, 10-11, 14 Girdano, D. A., 25, 32
and serotonin levels, 15 Goal-directedness and autogenic
and sleep disturbance, 15-16, training, 77, 80
174-175, 178 Goldberg, P., 177
stress in, 14 Golden, M., 13
symptoms of, 13 Goldenberg, D. L.
treatment of diagnosis of muscle pain, 10
with medication, 19-20 fibromyalgia
with physical therapy, 22-23 and depression and anxiety, 14
physical therapy compared to and gender, 13
hypnotherapy, 21 and sleep disturbance, 15
with stress management, 20-22 treating with NSAIDs, 19
Fibrositis, 10 treating with physical therapy, 22
Fine, T. H., 70 Goleman, D. T., 50
Flotation tanks, 68-69 Gray, M., 11
Focused attention. See Making mental Green, A. M., 96, 101, 165, 169
contact with body Green, E., 96, 101, 165, 169
Folkman, S., 28, 31, 32 Griep, E. N., 35
Forehead cooling exercise, 137-143 Grzesiak, R. C., 42
Formulas. See also Exercise(s) Guidelines for autogenic training, 96t
for autogenic biofeedback, 168
“I am at peace,” 80, 98
intentional, 149-150, 151t Haanen, H. C. M., 21
not changing, 187 Haddox, J. D., 2, 9
organ-specific, 148-149 Handedness, and starting exercises, 99
“tranquility,” 80, 98 Hands and feet, cold, 105
Foulks, E. F., 171 Hard muscles, 10
Fractioned hypnosis, 56 Hassett, J., 33
Fragmentation of self in response to Heart exercise, 113-118
pain, 3 Heaviness exercise, 95-104
Freedman, R. R., 60 Heide, F. J., 65
Friedman, R., 49 Hench, P. K., 22
Fuller, G., 39, 166 Hoenderdos, H. T. W., 21
Functional passivity, 77 Holmes, G. P., 11
Holmes, T. H., 27, 29
Horizontal position, 71, 74-75
Gallagher, R. M., 3-4, 20, 37 for abdominal warmth exercise,
GAS (General adaptation syndrome), 75f
30-31 general, 72f
Gastrointestinal disorders and abdominal for heart exercise, 74f
warmth exercise, 127 Hormones
Geissman, P., 60, 76 affected by REST, 69-70
General instructions before relaxation deficiencies in, 15-16
exercise, 85-86 and sleep, 180-181
Index 215
HPAC (hypothalamic-pituitary- Keck, P. E., 20
adrenocortical cortex) Keefe, F. J., 37
and REST, 69-70 Kerns, R. D., 3
and stress, 34-36 Klienheskel, S. M., 14
Hudson, J. I., 14
Hudson, M. S., 14
Hypnosis, 56, 57, 186 Labbe, E. L., 44
Hypnotherapy in treatment of Lavey, R. S., 42, 45
fibromyalgia, 21 Lazarus, A. A., 45, 63
Hypothalamic-pituitary-adrenocortical Lazarus, R. S., 27, 28, 31, 32
cortex (HPAC) Learned helplessness, 3
and REST, 69-70 Leavitt, F., 13
and stress, 34-36 Lehrer, P. M., 46, 50
Leshan, L., 3
Lichstein, K. L., 60
Ianni, P., 60 Lilly, J. C., 68, 69, 70
Imagery, 45-46 Lindemann, H., 57, 117, 134, 151
Immune system, affected by stress Lower back, relieving tension in
hormones, 70 in horizontal position, 71
Insights in autogenic meditation, 159, in reclined position, 71-73
160 Luce, G. G., 173
Insomnia. See Sleep Lue, F. A., 15
Intentional formulas, 149-150, 151t Luthe, W.
Interfactional model of stress, 31-32 on abdominal warmth exercise, 129,
Internal organs, 128 134
Intestinal sounds during abdominal on advanced autogenic techniques, 59
warmth exercise, 134-135 on autogenic discharges, 58
Irwin, M., 172 autogenic training described, 4-5, 44,
Isolation and stress reduction, 69 55, 61-62
“It breathes me,” explained, 121, 190 on benefits of heart exercise, 117
Iyengar, B. K. S., 47 on body-mind medicine, 56
conditions to be monitored during
training, 64-65, 65-66, 128
Jacobson, E., 46 diseases to be treated with autogenic
Janssen, K., 60 training, 44
Jencks, B. on forehead cooling exercise, 137
on benefits of autogenic training, 61 on formulas, 79
on breathing, 119, 120 hypnosis compared with autogenic
definition of “autogenic,” 44 training, 60-61
on heart exercise, 114, 117 intentional formulas, 150, 151t
on stress, 26 organ-specific formulas, 148, 149t
Jouvet, M., 15 on other breathing exercises, 120
Jus, A., 60, 76 on passive concentration, 77
Jus, K., 76 positions for training, 67, 113
on sleep, 56, 76, 161, 181
compared with autogenic training, 61
Kantz, C., 13 on visualizing people, 160
Kaufman, D., 177 on warmth exercise, 107, 108-109
“Magic bullets” for disease, 1-2 Mind-set, appropriate, 97-98
Making mental contact with body, Miskiman, D. E., 181
78-79, 81-82, 90-93 Mitler, M. M., 22
Mantra, 47 Mitral valve
Masi, A. T., 13 abnormalities in fibromyalgia, 12
Mayne, T. J., 63 prolapse and heart exercise, 114, 118
McCain, G. A., 20 Moldofsky, H., 15, 173, 174
McGill Pain Questionnaire, 13 Multiprocess model of stress and
McIlwain, H. H., 19 relaxation, 49-51
McLean, A. A., 26 Muscle pain and abdominal warmth,
Meadows, W. M., 60 131, 135
Medical conditions to be monitored Muscle tension, positions for
before starting training, 65 decreasing, 71-75
Medical screening for relaxation Muscles, tensing and relaxing, 86-90
techniques, 63, 64-66, 127-128, “Muskelharten,” 10
148-149, 190 Myofascial pain syndrome, compared
Medications to fibromyalgia, 16-17
lessened use related to relaxation Myofascial trigger points, 21, 22
therapy, 43
to be monitored during relaxation
therapy, 64, 127-128 Naps, benefits compared to using
used for fibromyalgia, 19-20 advanced formulas, 145-146
Medicine, biopsychosocial model of, Nathan, R. G., 25, 27
2-3 National Institutes of Health, on effect
Meditation, autogenic, 150-163 of relaxation on pain, 4
and achieving mind-body balance, Neck, relieving tension in when in
161-162 horizontal position, 71
case example, 162-163 Neiss, R., 46
colors, visualizing spontaneous, Nervous exhaustion, 11-12
152-153 Neurasthenia, 11-12
colors, visualizing suggested, Neurotransmitters, deficiencies in, 15
153-155 Neutgens, J., 60
concepts, visualizing, 157-158 Neutralization of disturbing stimuli, 4
feeling, experiencing a specific state Nicassio, P., 181
of, 159 Nonsteroidal anti-inflammatory agents
insights in, 159, 160 (NSAIDs) in treatment of
objects, visualizing, 155-157 fibromyalgia, 19
people, visualizing, 159-160 Noonberg, A. R., 39, 46
to be practiced only with therapist, Norris, P. A., 97
152, 159 NSAIDs (nonsteroidal anti-
Meditation, transcendental, 46-47, 49 inflammatory agents) in
Meichenbaum, D., 39, 40, 41 treatment of fibromyalgia, 19
Mental contact, making with body,
78-79, 81-82, 90-93
Mierzwa, J. A., 23, 60, 181 Objects, visualization of, 155-157
Miller, N. E., 187 Olton, D. S., 39, 46
Mind-body balance, achieving through O’Moore, A. M., 60
autogenic meditation, 161-162 Organ-specific formulas, 148-149, 149t
Index 217
Oriental medicine and nervous Psychoneuroimmunology, 27
exhaustion, 12 Psychophysiological treatment of pain,
Oringel, S. E., 50 3-4
Overweight patients and heaviness Psychophysiology of stress, 32-36
exercise, 186 hypothalamic pituitary-
adrenocortical system, 34-36
sympathetic-adrenal medullary
PACE (Pain, Activity, Conditioning, system, 33-34, 36
Education), 22-23
Pain, 9
Pain management Quiet room, need for, 70-71, 81
goals of, 2
multidisciplinary approach to, 5-6, 24
Pain medications and sleep, 180 Rag doll posture, 146-148
Paracelsus, 6 Rahe, R. H., 27, 29
Parasympathetic rebound, 66 Rama, S., 48
Passive concentration, 59, 75-78, 81, 152 Raynaud’s disease, 34
Pasteur, Louis, Germ Theory, 1 Reclined position, 72f
Patel, C., 48 Relaxation
Pathogenic origins of disease, 1 difficulty in achieving, 185-186
Pellegrino, M. J., 12 techniques
Pelletier, K. P., 42, 44, 45, 51-52, 61 models of, 48-51
People, visualizing, 159-160 positions for, 71-75
Personality, effect of on coping with training, 42-43
pain, 2-3 medical screening for, 63, 64-66
Phrases, repeating, 79-80, 82. See also side effects of, 63
Exercise(s); Formulas Repeating phrases, 79-80, 82. See also
Physical therapy in treating Exercise(s); Formulas
fibromyalgia, 22-23 Replenishment exercises, 145-148
Pliner, L. F., 14 Requirements for autogenic training,
Polatin, P. B., 2-3 67-68, 70-82
Positions for relaxation, 71-75, 86, Respiration exercise, 119-125
146-148 autogenic compared with other
Posttraumatic pain and autogenic breathing techniques, 120
meditation, 160 Response model of stress, 30-31
Posttraumatic stress and autogenic REST (restricted environmental
training, 60, 124-125 stimulation therapies), 68-70
Practice, daily, 80-81, 82 Rice, J. R., 14
Preliminary exercises, 85-93 Russell, I. J., 10, 15, 19
Preparing for autogenic training, 85-93
Progressive relaxation, 46, 49
Prophylactic rest-autohypnosis, 56 Sackheim, H. A., 25
Psychobiological disregulation and Sadigh, M. R.
fibromyalgia, 23-24 biofeedback study, 21
Psychogenic rheumatism, 10 on chronic pain, 9
Psychological conditions to be and personality disorders, 2-3
monitored before and during and stress, 14
autogenic training, 65-66 on posttraumatic stress, 60, 124-125
Sadigh, M. R. (continued) Simons, D. G., 10, 12, 16
on psychobiological disregulation Sitting position(s), 71-74
and fibromyalgia, 23 Sklar, L. S., 26, 27
on sleep, 181 Sleep
Sadler, William, and neurasthenia, 11 and autogenic meditation, 163
Sakai, M., 60 changes brought on by, 172
SAM (sympathetic-adrenal medullar) disturbance of in fibromyalgia
and stress, 33-34, 36 patients, 15-16, 174-175
Sargent, J. D., 165 exercises to promote, 181-184
Schneiderman, N., 35 need for, 171-172, 173
Schultz, Johannes H. rapid-eye movement stage, 173-174
on abdominal warmth exercise, 129, rituals to achieve, 171-172, 182-184
134 stages of, 172-173
on autogenic discharges, 58 steps to improving, 176-177, 178-181
autogenic training described, 44, 55, Sleep restriction to improve sleep,
61-62 179-180
on body-mind medicine, 56 Sleep state compared to autogenic state,
conditions to be monitored during 60, 76-77, 77f
training, 128 Smith, J. C., 45, 119
on formulas, 79 Smith, T., 172
on Hatha Yoga, 48 Smythe, H. A., 17, 18
hypnosis compared with autogenic Social Readjustment Rating Scale
training, 59-60 (SRRS), 27-28, 29t
intentional formulas, 150, 151t Solar plexus, location of, 127, 128f
and mind-body studies, 57-59 Somatic relaxation, 49-50
organ-specific formulas, 148, 149t SRRS (Social Readjustment Rating
on other breathing exercises, 120 Scale), 27-28, 29t
on passive concentration, 59, 77 Standard Autogenic Training Exercises,
postures for training, 67, 113 57-58
and relaxation therapy, 42 Sternbach, R. A., 9
on sleep, 56, 181 Stimulation, reducing in environment,
on visualizing people, 160 67-71, 81
on warmth exercise, 107, 108-109 Stimulus model of stress, 27-29
Schwartz, D. P., 43 Stoyva, J., 37, 39, 42
Schwartz, G. E., 23, 45, 49, 50, 114 Stress
Scita, F., 20-21 compared to chronic pain, 25
Scudds, R. A., 20 correlation with psychological and
Self-healing mechanisms, damage to, 58 physical symptoms, 25
Seligman, M. E. P., 3 definitions of, 26-27, 30, 32
Selye, H., 25, 30-31, 34, 35, 70 management techniques, 37-48,
Semble, E. L., 10, 12 145-148
Sensory deprivation studies, 68-69 autogenic training, 44
Serotonin levels in fibromyalgia biofeedback, 39-40
patients, 15 breathing exercises, 44-45
Shoulders, relieving tension in when in cognitive restructuring, 38-39
reclining position, 71 imagery, 45-46
Side effects of relaxation techniques, 63 progressive relaxation, 46, 49
Sim, J., 13 relaxation training, 42-43
Index 219
Stress, management techniques Turk, D. C., 39, 40
(continued) Turner, J. A., 43
stress inoculation, 40-41 Turner, J. W., 70
transcendental meditation, 46-47, Twain, Mark, and insomnia, 177
49 Tyrell, J. B., 35
Yoga training, 47-48
models of, 27-32
and physical disorders, 26 Unitary model of stress and relaxation,
psychophysiology of, 32-36 49
Stress management in treating
fibromyalgia, 20-22
Stress syndrome, stages of, 30-31 Vahia, N. S., 47, 48
Suedfeld, P., 68 Van Horn, Y., 37
Suffering, experience of, 3 Van Romunde, L. K. J., 21
Sympathetic-adrenal medullar (SAM) Vgontzas, A. N., 172, 173
and stress, 33-34, 36 Visualization. See Meditation,
Symptom Checklist, 90 Revised autogenic
(SCL-90-R), 21 Vogt, Oskar and Cecil, and autogenic
Symptom-focused formulas. See training, 55-56
Intentional formulas von Bertalanffy, L., 23
Symptoms of distress, 31
Wake-sleep continuum, 76-77, 77f
Walczyk, J., 16
Tapp, J. T., 35 Walters, E. D., 165
Tarler-Benlolo, L., 40 Warm water immersion, 110
Taylor, C. B., 42, 45 Warmth
Temporomandibular joint disorder abdominal, 127-131
(TMJD), 88, 99 creating in arms, 107
Tender points in fibromyalgia, 12-13, and reducing anxiety, 105-106
17 Warmth exercise, 105-111
Tensing and relaxing muscles, 86-90 Weber, S. L., 25
Therapist, lack of dependence on, Weiner, H., 1
57-58 Weing, P., 60
Thomas, K., 103 Weiss, R. J., 68
Time required for exercises, 189-190 Welge, J. A., 20
TMJD (temporomandibular joint Williamson, D. A., 44
disorder), 88, 99 Wise, C. M., 10, 12
Tollison, C. D., 3 Withdrawal as a response to pain, 3
Transactional model of stress. See Wolfe, F., 14, 17
Interfactional model of stress Wolpe, J., 46
Transcendental meditation, 46-47 Woolfolk, R. L., 46, 50
as treatment for insomnia, 181
Traumatic experiences, brought out by
autogenic exercises, 58 Yoga, 47-48
Travell, J., 16, 17 combining with autogenic training,
Treadwell, B. J., 20 187
Trigger points, 17, 21, 22 Yunus, M. B., 10, 13, 14, 17,18

Autogenic Training

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Micah R.

ing and highlights its benefits, Dr.

“D r. Sadigh provides clinicians

Kenneth Anchor, PhD

The Haworth Medical Press®

CONSERVATION AND PRESERVATION NOTES

Roberto Patarca-Montero, MD, PhD

Concise Encyclopedia of Chronic Fatigue Syndrome by Roberto

CFIDS, Fibromyalgia, and the Virus-Allergy Link: Hidden Viruses,

Adolescence and Myalgic Encephalomyelitis/Chronic Fatigue

Phytotherapy of Chronic Fatigue Syndrome: Evidence-Based

Autogenic Training: A Mind-Body Approach to the Treatment

Enteroviral and Toxin Mediated Myalgic Encephalomyelitis/

Treatment of Chronic Fatigue Syndrome in the Antiviral Revolution

Micah R. Sadigh, PhD

The Haworth Medical Press®

Cover design by Marylouise E. Doyle.

Library of Congress Cataloging-in-Publication Data

Micah R. Sadigh, PhD, is a respected psychologist and research sci-

PART I: THEORETICAL ASPECTS OF CHRONIC PAIN

Chapter 2. Stress and Pain 25

Chapter 3. Methods of Stress Management 37

Chapter 5. Autogenic Training:

Chapter 6. Requirements for Achieving

Chapter 9. The Second Standard Exercise: Warmth 105

Chapter 10. The Third Standard Exercise: Heart 113

Chapter 11. The Fourth Standard Exercise: Respiration 119

Chapter 12. The Fifth Standard Exercise:

Chapter 13. The Sixth Standard Exercise:

I first studied autogenic training under the auspices of Dr. Durand

behaviors by providing patients with more healthy and constructive

My exploration of autogenic training began in 1979 when I was

ORGANIZATION OF THE BOOK

chapters are dedicated to advanced autogenic training, autogenic bio-

Was vergangen kehrt nicht wieder,

as quoted in Marquardt, 1949

This is a tremendous opportunity to express my gratitude to my

To my wonderful students at Cedar Crest College, I owe special

Micah R. Sadigh, PhD

The nineteenth-century revolution in medicine brought about sig-

fails to account for psychological, environmental, and stress-related

and colleagues (1993) found a high prevalence of personality disor-

(1997) suggested that such techniques can significantly affect pain

One of the most important assumptions of autogenic training is

designed to support and facilitate the natural self-healing mech-

In a sense, this technique simply activates, supports and enhances

therapeutic approaches such as pharmacotherapy, physical therapy,

Fibromyalgia Pain Syndrome:

Chronic pain is a complex phenomenon that can have profound

10 billion dollars annually (Russell, 1994). Currently, fibromyalgia

ents, to cultural and religious changes. It was believed that certain

significantly more distinguishable tender points than those in the

DEPRESSION AND ANXIETY

As it was mentioned earlier, depression is often a concomitant of

FIBROMYALGIA AND SLEEP DISTURBANCE

Another common complaint of patients suffering from this syn-

production is intimately linked to somatotropin and is similar to insu-

FIBROMYALGIA AND MYOFASCIAL PAIN SYNDROME

Although there are a number of similarities between fibromyalgia

The American College of Rheumatology has suggested specific

Another important criterion is the presence of eleven out of eighteen

1. History of widespread pain

2. Pain in 11 of 18 tender points on digital palpation